Healthcare Provider Details

I. General information

NPI: 1235046392
Provider Name (Legal Business Name): REVOLUTION WELLNESS NP IN ADULT HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 S BICYCLE PATH
FARMINGVILLE NY
11738-2124
US

IV. Provider business mailing address

121 MAIN ST # 1007
NORTHPORT NY
11768-1721
US

V. Phone/Fax

Practice location:
  • Phone: 631-997-8799
  • Fax:
Mailing address:
  • Phone: 631-997-8799
  • Fax: 209-589-0420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JELISA DOPWELL
Title or Position: OWNER
Credential: DNP
Phone: 631-997-8799