Provider Demographics
NPI:1780048124
Name:DEGRAZIA WELLNESS, LLC
Entity type:Organization
Organization Name:DEGRAZIA WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:STULTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-890-5217
Mailing Address - Street 1:3210 HILLCREST PARK DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7693
Mailing Address - Country:US
Mailing Address - Phone:541-494-8888
Mailing Address - Fax:541-494-1300
Practice Address - Street 1:3210 HILLCREST PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7693
Practice Address - Country:US
Practice Address - Phone:541-494-8888
Practice Address - Fax:541-494-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201500652NP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty