Healthcare Provider Details

I. General information

NPI: 1265365050
Provider Name (Legal Business Name): ADVANCED HOME WOUND HEALING & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 SWINNERTON ST
STATEN ISLAND NY
10307-1644
US

IV. Provider business mailing address

357 SWINNERTON ST
STATEN ISLAND NY
10307-1644
US

V. Phone/Fax

Practice location:
  • Phone: 609-442-6803
  • Fax:
Mailing address:
  • Phone: 609-442-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DIMYANA ATA
Title or Position: OWNER
Credential: PA-C
Phone: 973-489-9615