Provider Demographics
NPI:1457139354
Name:MIND BODY SOUL WONDERFULLY MADE
Entity Type:Organization
Organization Name:MIND BODY SOUL WONDERFULLY MADE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, PMHNP
Authorized Official - Phone:757-966-1270
Mailing Address - Street 1:355 CRAWFORD ST STE 102
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-2817
Mailing Address - Country:US
Mailing Address - Phone:757-966-1270
Mailing Address - Fax:757-966-2967
Practice Address - Street 1:355 CRAWFORD ST STE 102
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-2817
Practice Address - Country:US
Practice Address - Phone:757-966-1270
Practice Address - Fax:757-966-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty