Provider Demographics
NPI:1992433916
Name:WELLNESS LEGACY LLC
Entity type:Organization
Organization Name:WELLNESS LEGACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO -OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK ANTHONY
Authorized Official - Middle Name:BERGONIA
Authorized Official - Last Name:ISON
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP- PMH
Authorized Official - Phone:410-286-1258
Mailing Address - Street 1:1539 BLAKES LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-1946
Mailing Address - Country:US
Mailing Address - Phone:410-286-1258
Mailing Address - Fax:443-231-3684
Practice Address - Street 1:1016 DULANEY VALLEY RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2702
Practice Address - Country:US
Practice Address - Phone:410-286-1258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLNESS LEGACY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-09
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty