Provider Demographics
NPI:1760093025
Name:REVITALIZED WELLNESS PLLC
Entity Type:Organization
Organization Name:REVITALIZED WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:251-979-9825
Mailing Address - Street 1:401 E 8TH ST STE 214-7054
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-7011
Mailing Address - Country:US
Mailing Address - Phone:605-423-7557
Mailing Address - Fax:605-305-1175
Practice Address - Street 1:326 E 8TH ST APT 206
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-7038
Practice Address - Country:US
Practice Address - Phone:605-423-7557
Practice Address - Fax:605-305-1175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty