Balanced Wellness Primary Care, LLC
Organization Active NPI Family Nurse Practitioner · Uncasville, CT
NPI 1780926774 · NPPES record last updated Jun 17, 2022
Key facts
- NPI
- 1780926774
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- 004797 (CT)
- Legal business name
- BALANCED WELLNESS PRIMARY CARE, LLC
- Practice address
- 620 Norwich New London Tpke
Uncasville, CT 06382 - Phone
- (860) 892-8012
- Fax
- (860) 892-8027
- NPI assigned
- Mar 18, 2013
- Organization subpart
- No
Authorized official
- Name
- Kristin Marie Mahan
- Title
- Owner
- Phone
- (860) 892-8012
Practitioners 6
-
Joseph F O'Keefe, M.D.
-
Kathleen Eagle, MSN, APRN, FNP-C
-
Tracy Michele Jullarine, APRN
-
Lynda Mary Lombardi, NP-C
-
Danielle Lee Mallory, APRN FNP-BC
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 07D2059302 | Balanced Wellness Primary Care, LLC | Certificate of waiver | May 20, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CT
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130815000546 | CT | Part B Supplier - Clinic/Group Practice | 6901048255 |
Receives reassigned benefits from 6 practitioners Practice locations: Uncasville, CT |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner |
363LF0000X | 004797 | CT | Yes |
Addresses
Primary practice location
620 Norwich New London Tpke
Uncasville, CT 06382
Mailing address
620 Norwich New London Tpke
Uncasville, CT 06382
Phone (860) 892-8012
Other providers in Uncasville, CT
- Judith Olson Applegate
- Bethany Grace Arabic
- Michel-Ange Aurelus-Joseph
- Cassie Babcock
- Bruce E Bailey
- Richard Bennink
- Amber Brooks
- Tammy Brown
- Stephen Gerard Burke
- Sydney Byrd
All providers in Uncasville, CT · Family Nurse Practitioner in Connecticut
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 17, 2022. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.