Provider Demographics
NPI:1861364960
Name:DERA WELLNESS LLC
Entity type:Organization
Organization Name:DERA WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHIDINMA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNDU
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:617-372-2571
Mailing Address - Street 1:2428 GREEN RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ROYSE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75189-6088
Mailing Address - Country:US
Mailing Address - Phone:616-173-7225
Mailing Address - Fax:469-721-0500
Practice Address - Street 1:2428 GREEN RIVER RD
Practice Address - Street 2:
Practice Address - City:ROYSE CITY
Practice Address - State:TX
Practice Address - Zip Code:75189-6088
Practice Address - Country:US
Practice Address - Phone:616-173-7225
Practice Address - Fax:469-721-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty