Provider Demographics
NPI:1134777576
Name:WELLNESS LEGACY LLC
Entity type:Organization
Organization Name:WELLNESS LEGACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ISON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-286-1258
Mailing Address - Street 1:1539 BLAKES LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-1946
Mailing Address - Country:US
Mailing Address - Phone:817-319-6878
Mailing Address - Fax:443-231-3684
Practice Address - Street 1:260 GATEWAY DR STE 13
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4268
Practice Address - Country:US
Practice Address - Phone:410-286-1258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty