Provider Demographics
NPI:1891369823
Name:HOLISTIC WELLNESS GROUP, LLC
Entity Type:Organization
Organization Name:HOLISTIC WELLNESS GROUP, LLC
Other - Org Name:HOLISTIC WELLNESS GROUP, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESCRIBER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:205-430-9966
Mailing Address - Street 1:125 COBB DR
Mailing Address - Street 2:
Mailing Address - City:JEMISON
Mailing Address - State:AL
Mailing Address - Zip Code:35085-4197
Mailing Address - Country:US
Mailing Address - Phone:205-430-9966
Mailing Address - Fax:915-223-1562
Practice Address - Street 1:808 LAY DAM RD
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-2943
Practice Address - Country:US
Practice Address - Phone:205-369-1273
Practice Address - Fax:205-369-1273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL270189Medicaid