Provider Demographics
NPI:1396312948
Name:WELLNESS FUNDAMENTALS INC.
Entity type:Organization
Organization Name:WELLNESS FUNDAMENTALS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYSURA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:917-346-1806
Mailing Address - Street 1:PO BOX 651
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-0651
Mailing Address - Country:US
Mailing Address - Phone:917-346-1806
Mailing Address - Fax:
Practice Address - Street 1:100 ALCOTT PL APT 4K
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4153
Practice Address - Country:US
Practice Address - Phone:917-346-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty