Provider Demographics
NPI:1184340291
Name:THE WELLNESS COOPERATIVE
Entity type:Organization
Organization Name:THE WELLNESS COOPERATIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING MEMBER, FNP-C
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:503-791-2816
Mailing Address - Street 1:714 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-4738
Mailing Address - Country:US
Mailing Address - Phone:503-791-2816
Mailing Address - Fax:866-638-1928
Practice Address - Street 1:714 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-4738
Practice Address - Country:US
Practice Address - Phone:503-791-2816
Practice Address - Fax:866-638-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty