Provider Demographics
NPI:1902503451
Name:LUNA WELLNESS, PLLC
Entity Type:Organization
Organization Name:LUNA WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, NP
Authorized Official - Prefix:MS
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:BEAUREGARD
Authorized Official - Last Name:KELAMIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:571-271-3139
Mailing Address - Street 1:2905 N ROM ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4679
Mailing Address - Country:US
Mailing Address - Phone:571-271-3139
Mailing Address - Fax:
Practice Address - Street 1:2905 N ROM ORCHARD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4679
Practice Address - Country:US
Practice Address - Phone:571-271-3139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service