Healthcare Provider Details

I. General information

NPI: 1831003250
Provider Name (Legal Business Name): REVIVE HYDRATION PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST
RED BUD IL
62278-1212
US

IV. Provider business mailing address

4740 KANE HILL RD
ELLIS GROVE IL
62241-1728
US

V. Phone/Fax

Practice location:
  • Phone: 618-408-1248
  • Fax:
Mailing address:
  • Phone: 618-408-1248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: JENNIFER KNOTT
Title or Position: OWNER / MEMBER
Credential: APRN, PMHNP-BC
Phone: 618-615-8898