MEDICARE: JOMON WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1922853860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOMON WELLNESS LLC

Provider Business Mailing Address
First Line	:	132 FRONTIER BLVD STE 103
Second Line	:
City	:	STANFORD
State	:	KY
Zip	:	40484-6516
Country	:	US
Telephone Number	:	859-287-2949
Fax Number	:	855-297-6367

Provider Business Practice Location Address
First Line	:	132 FRONTIER BLVD STE 103
Second Line	:
City	:	STANFORD
State	:	KY
Zip	:	40484-6516
Country	:	US
Telephone Number	:	859-287-2949
Fax Number	:	855-297-6367

Authorized Official
Title or Position	:	OWNER/NP
Name	:	MRS. TRACY BOLLER
Credential	:	NP
Telephone Number	:	859-287-2949

Provider Enumeration Date	:	04/23/2024
Last Update Date	:	11/20/2025

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Directions to “JOMON WELLNESS LLC ” Practice Location

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