Provider Demographics
NPI:1043041148
Name:ADVANCED PURE WELLNESS LLC.
Entity type:Organization
Organization Name:ADVANCED PURE WELLNESS LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONK
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:267-724-9300
Mailing Address - Street 1:81 BIG OAK RD
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7801
Mailing Address - Country:US
Mailing Address - Phone:267-724-9300
Mailing Address - Fax:
Practice Address - Street 1:81 BIG OAK RD
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7801
Practice Address - Country:US
Practice Address - Phone:267-724-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-10
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty