Provider Demographics
NPI:1053892620
Name:MMA WELLNESS
Entity type:Organization
Organization Name:MMA WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:MARGARET
Authorized Official - Last Name:ANDREWS
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-C
Authorized Official - Phone:850-814-6562
Mailing Address - Street 1:1417 MAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-2129
Mailing Address - Country:US
Mailing Address - Phone:850-788-3120
Mailing Address - Fax:
Practice Address - Street 1:2428 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4304
Practice Address - Country:US
Practice Address - Phone:850-788-3120
Practice Address - Fax:850-788-3125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MMA WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-22
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9266378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty