Provider Demographics
NPI:1700284056
Name:CLINIC AND WELLNESS CENTERS, PLLC
Entity Type:Organization
Organization Name:CLINIC AND WELLNESS CENTERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:LASHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:817-209-7736
Mailing Address - Street 1:2771 E BROAD ST STE 217-109
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9156
Mailing Address - Country:US
Mailing Address - Phone:817-209-7736
Mailing Address - Fax:
Practice Address - Street 1:2771 E BROAD ST STE 217-109
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9156
Practice Address - Country:US
Practice Address - Phone:817-209-7736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0814245261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center