Healthcare Provider Details

I. General information

NPI: 1003656919
Provider Name (Legal Business Name): ADVANCED PRACTICE AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 S VOLUSIA AVE STE B3
ORANGE CITY FL
32763-7625
US

IV. Provider business mailing address

2425 S VOLUSIA AVE STE B3
ORANGE CITY FL
32763-7625
US

V. Phone/Fax

Practice location:
  • Phone: 386-473-7005
  • Fax: 386-473-7006
Mailing address:
  • Phone: 386-473-7005
  • Fax: 386-473-7006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY WADE PRINCE
Title or Position: CO-OWNER
Credential:
Phone: 256-612-0173