Healthcare Provider Details

I. General information

NPI: 1255068425
Provider Name (Legal Business Name): REVIVE HEALTH AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2022
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 BIENVILLE BLVD STE M1
OCEAN SPRINGS MS
39564-3027
US

IV. Provider business mailing address

17804 RIVERWALK DRIVE
VANCLEAVE MS
39565
US

V. Phone/Fax

Practice location:
  • Phone: 228-324-5347
  • Fax:
Mailing address:
  • Phone: 228-324-5347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TRACI J WHITE
Title or Position: OWNER
Credential: NP
Phone: 228-324-5347