Organization
WELLNESS LEGACY LLC
Active
Parent organization
WELLNESS LEGACY LLC
Other names
Wellness Legacy LLC
Organization subpart
Yes
Provider details
NPI number
Legal business name
WELLNESS LEGACY LLC
Authorized official
MARK ANTHONY BERGONIA ISON CRNP- PMH (CO -OWNER)
(410) 286-1258
Entity
Organization
Contact information
Practice address
1016 DULANEY VALLEY RD, TOWSON, MD 21204-2702
(410) 286-1258
Mailing address
1539 BLAKES LEGACY DR, BEL AIR, MD 21014-1946
(410) 286-1258
(443) 231-3684
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Enumeration date
08/09/2022
Last updated
03/27/2024
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