Provider Demographics
NPI:1851091680
Name:ADVANCE HEALTHCARE & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:ADVANCE HEALTHCARE & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP-C /OWNER MEDICAL CLINIC
Authorized Official - Prefix:
Authorized Official - First Name:LATONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:901-216-7457
Mailing Address - Street 1:8093 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-5619
Mailing Address - Country:US
Mailing Address - Phone:901-216-7457
Mailing Address - Fax:
Practice Address - Street 1:1331 UNION AVE STE 1148B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-7509
Practice Address - Country:US
Practice Address - Phone:901-216-7457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty