Provider Demographics
NPI:1851717797
Name:WELLNESS CLINIC AND MEDICAL SPA LLC
Entity Type:Organization
Organization Name:WELLNESS CLINIC AND MEDICAL SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEWBRE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-GNP
Authorized Official - Phone:405-527-4704
Mailing Address - Street 1:PO BOX 269031
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9031
Mailing Address - Country:US
Mailing Address - Phone:877-485-4474
Mailing Address - Fax:405-527-5976
Practice Address - Street 1:128 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-4220
Practice Address - Country:US
Practice Address - Phone:405-527-4704
Practice Address - Fax:405-527-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK49456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty