Provider Demographics
NPI:1821856394
Name:VISTA BLUE HEALTH AND WELLNESS LLC
Entity Type:Organization
Organization Name:VISTA BLUE HEALTH AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER/OWNER/PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HASBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:216-910-7451
Mailing Address - Street 1:6545 MARKET AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44721-2430
Mailing Address - Country:US
Mailing Address - Phone:216-910-7451
Mailing Address - Fax:
Practice Address - Street 1:6545 MARKET AVE N STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-2430
Practice Address - Country:US
Practice Address - Phone:216-973-2087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-11
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1235747700Medicaid
OH1659983252Medicaid
OH1770905226Medicaid