Provider Demographics
NPI:1881132660
Name:DE MORGAN WELLNESS GROUP
Entity type:Organization
Organization Name:DE MORGAN WELLNESS GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:937-247-6360
Mailing Address - Street 1:7271 N MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2561
Mailing Address - Country:US
Mailing Address - Phone:937-991-0082
Mailing Address - Fax:937-771-0836
Practice Address - Street 1:7271 N MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2561
Practice Address - Country:US
Practice Address - Phone:937-609-0566
Practice Address - Fax:937-991-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-01
Last Update Date:2024-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X, 261QP2300X
OHCOA07003NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1871685792OtherINDIVIDUAL NPI
OH1881132660OtherNPI
OH2388901Medicaid