Provider Demographics
NPI:1679458988
Name:OPTIMAL HOLISTIC MEDICINE
Entity type:Organization
Organization Name:OPTIMAL HOLISTIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENALYN
Authorized Official - Middle Name:V
Authorized Official - Last Name:LICEA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:864-334-7227
Mailing Address - Street 1:2050 FARM WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-6796
Mailing Address - Country:US
Mailing Address - Phone:864-334-7227
Mailing Address - Fax:
Practice Address - Street 1:2050 FARM WAY
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-6796
Practice Address - Country:US
Practice Address - Phone:864-334-7227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty