Provider Demographics
NPI:1932690658
Name:ALLEGIANT HEALTH SERVICES
Entity Type:Organization
Organization Name:ALLEGIANT HEALTH SERVICES
Other - Org Name:WHOLE FAMILY WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYSHEENA
Authorized Official - Middle Name:LANEE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:757-344-0822
Mailing Address - Street 1:4209 RAVINE GAP DR
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-3055
Mailing Address - Country:US
Mailing Address - Phone:757-344-0822
Mailing Address - Fax:507-609-3013
Practice Address - Street 1:2147 OLD GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2635
Practice Address - Country:US
Practice Address - Phone:757-306-1300
Practice Address - Fax:507-609-3013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024174111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAI10OtherMEDICARE NUMBER