Provider Demographics
NPI:1740079623
Name:BOLD ARK LLC
Entity type:Organization
Organization Name:BOLD ARK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:OLUFUNKE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADEWUNMI
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHNP-BC
Authorized Official - Phone:773-441-2826
Mailing Address - Street 1:4652 LAWRENCEVILLE HWY NW STE 101
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4652 LAWRENCEVILLE HWY NW STE 101
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-3623
Practice Address - Country:US
Practice Address - Phone:678-898-1927
Practice Address - Fax:678-798-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-06
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty