Provider Demographics
NPI:1548076490
Name:PROVIDENCE WELLNESS, LLC
Entity type:Organization
Organization Name:PROVIDENCE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAPPS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:601-955-4039
Mailing Address - Street 1:206 GRAND OAK BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-6040
Mailing Address - Country:US
Mailing Address - Phone:601-955-4039
Mailing Address - Fax:
Practice Address - Street 1:4490 HIGHWAY 80 E STE A
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-4206
Practice Address - Country:US
Practice Address - Phone:601-335-8600
Practice Address - Fax:240-219-3126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-05
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty