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General NPI Number Information
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NPI Number | 1740079623
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Entity Type | Organization
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Legal Business Name | BOLD ARK LLC
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Dates
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Enumeration Date | 05/06/2025
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 4652 LAWRENCEVILLE HWY NW STE 101
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City | LILBURN
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State | GA
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Zip | 30047-3623
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Country | US
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Telephone | 678-898-1927
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Fax | 678-798-8880
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Provider Business Mailing Address
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Address Line | 4652 LAWRENCEVILLE HWY NW STE 101
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City | LILBURN
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State | GA
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Zip | 30047-3623
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | OLUFUNKE ADEWUNMI
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Credential | DNP, PMHNP-BC
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Telephone | 773-441-2826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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