Provider Demographics
NPI:1669286605
Name:WELLNESS ROOTS NEXUS
Entity type:Organization
Organization Name:WELLNESS ROOTS NEXUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LAUREN
Authorized Official - Last Name:MAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PA-C, RD
Authorized Official - Phone:417-224-1401
Mailing Address - Street 1:3608 W EL CASTILE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1213 S KIMBROUGH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1626
Practice Address - Country:US
Practice Address - Phone:417-224-1401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service