Healthcare Provider Details

I. General information

NPI: 1053159996
Provider Name (Legal Business Name): REVIVING WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 08/23/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3336 E CHANDLER HEIGHTS RD STE 123
GILBERT AZ
85298-4263
US

IV. Provider business mailing address

3336 E CHANDLER HEIGHTS RD STE 123
GILBERT AZ
85298-4263
US

V. Phone/Fax

Practice location:
  • Phone: 480-923-9094
  • Fax:
Mailing address:
  • Phone: 480-923-9094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CARRIE MARTINSON
Title or Position: OWNER
Credential: NP
Phone: 480-923-9094