Provider Demographics
NPI:1063000479
Name:REJUVENATED HEALTH & WELLNESS
Entity Type:Organization
Organization Name:REJUVENATED HEALTH & WELLNESS
Other - Org Name:REJUVENATED HEALTH & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:DAYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-201-8289
Mailing Address - Street 1:PO BOX 10837
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-0837
Mailing Address - Country:US
Mailing Address - Phone:928-201-8289
Mailing Address - Fax:
Practice Address - Street 1:5221 S HIGHWAY 95 STE 13
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9244
Practice Address - Country:US
Practice Address - Phone:928-234-7572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NIPPIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-02
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty