Healthcare Provider Details

I. General information

NPI: 1124809801
Provider Name (Legal Business Name): LIFTUP LIVEWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 TOWN SQUARE PL STE 803054
JERSEY CITY NJ
07310-1755
US

IV. Provider business mailing address

111 TOWN SQUARE PL STE 803054
JERSEY CITY NJ
07310-1755
US

V. Phone/Fax

Practice location:
  • Phone: 212-918-4488
  • Fax:
Mailing address:
  • Phone: 212-918-4488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NERISA BRYAN
Title or Position: OWNER
Credential: APN
Phone: 212-918-4488