Healthcare Provider Details

I. General information

NPI: 1255130621
Provider Name (Legal Business Name): REVIVALIFE HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NEW YORK AVE STE 103
DELAND FL
32724-5576
US

IV. Provider business mailing address

100 E. NEW YORK AVE STE 103 #1011
DELAND FL
32724-5576
US

V. Phone/Fax

Practice location:
  • Phone: 407-901-7215
  • Fax:
Mailing address:
  • Phone: 407-801-1065
  • Fax: 407-801-1065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EMILY HIDALGO
Title or Position: MANAGING MEMBER
Credential:
Phone: 407-801-1065