Provider Demographics
NPI:1265173157
Name:PLATINUM WELLNESS LLC
Entity type:Organization
Organization Name:PLATINUM WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANNICK-KONOPCZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-254-0099
Mailing Address - Street 1:1213 PIPER BLVD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1393
Mailing Address - Country:US
Mailing Address - Phone:239-254-0099
Mailing Address - Fax:239-254-1908
Practice Address - Street 1:1213 PIPER BLVD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1393
Practice Address - Country:US
Practice Address - Phone:239-254-0099
Practice Address - Fax:239-254-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275067800Medicaid