Provider Demographics
NPI:1154172773
Name:WELLNESS360 PRIMARY CARE
Entity type:Organization
Organization Name:WELLNESS360 PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:764-670-2685
Mailing Address - Street 1:1700 SE HILLMOOR DR STE 305
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 SE HILLMOOR DR STE 305
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7536
Practice Address - Country:US
Practice Address - Phone:772-292-8188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty