# WELLNESS LEGACY LLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Parent organization:** WELLNESS LEGACY LLC
- **Other names:** Wellness Legacy LLC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1992433916
- **Legal business name:** WELLNESS LEGACY LLC
- **Authorized official:** MARK ANTHONY BERGONIA ISON CRNP- PMH (CO -OWNER)
- **Authorized official phone:** (410) 286-1258

## Contact information

- **Practice address:** 1016 DULANEY VALLEY RD, TOWSON, MD 21204-2702
- **Practice address phone:** (410) 286-1258
- **Mailing address:** 1539 BLAKES LEGACY DR, BEL AIR, MD 21014-1946
- **Mailing address phone:** (410) 286-1258
- **Mailing address fax:** (443) 231-3684

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 08/09/2022
- **Last updated:** 03/27/2024