Provider Demographics
NPI:1790548105
Name:REVITAL HEALTH AND WELLNESS PLLC
Entity Type:Organization
Organization Name:REVITAL HEALTH AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:IFEMESIA
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:631-220-8213
Mailing Address - Street 1:5900 BALCONES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-4298
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:402 W WHEATLAND RD STE 150
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4627
Practice Address - Country:US
Practice Address - Phone:631-220-8213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-31
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care