Healthcare Provider Details

I. General information

NPI: 1194647172
Provider Name (Legal Business Name): REVITALIZE YOUR WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12025 276TH AVE NW
ZIMMERMAN MN
55398-8923
US

IV. Provider business mailing address

12025 276TH AVE NW
ZIMMERMAN MN
55398-8923
US

V. Phone/Fax

Practice location:
  • Phone: 651-416-1301
  • Fax:
Mailing address:
  • Phone: 651-416-1301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MIKAYLA ELLEN SIEMSEN
Title or Position: FAMILY NURSE PRACTITIONER
Credential: FNP
Phone: 651-416-1301