Provider Demographics
NPI:1922853860
Name:JOMON WELLNESS LLC
Entity type:Organization
Organization Name:JOMON WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:859-287-2949
Mailing Address - Street 1:132 FRONTIER BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:KY
Mailing Address - Zip Code:40484-6516
Mailing Address - Country:US
Mailing Address - Phone:859-287-2949
Mailing Address - Fax:855-297-6367
Practice Address - Street 1:132 FRONTIER BLVD STE 103
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:KY
Practice Address - Zip Code:40484-6516
Practice Address - Country:US
Practice Address - Phone:859-287-2949
Practice Address - Fax:855-297-6367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-23
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty