Provider Demographics
NPI:1831916451
Name:VITAL BRANCH WELLNESS SOLUTIONS LLC
Entity type:Organization
Organization Name:VITAL BRANCH WELLNESS SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-CNP
Authorized Official - Phone:318-773-8241
Mailing Address - Street 1:2829 YOUREE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8156 MYRTLEWOOD RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:LA
Practice Address - Zip Code:71033-3024
Practice Address - Country:US
Practice Address - Phone:318-773-8241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LS0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerSchool