Healthcare Provider Details

I. General information

NPI: 1790640415
Provider Name (Legal Business Name): LIFTUP LIVEWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 MAIN ST STE 216
NYACK NY
10960-3109
US

IV. Provider business mailing address

99 MAIN ST STE 216
NYACK NY
10960-3109
US

V. Phone/Fax

Practice location:
  • Phone: 332-999-9641
  • Fax:
Mailing address:
  • Phone: 332-999-9641
  • 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: MS. NERISA BRYAN
Title or Position: NP
Credential:
Phone: 929-486-0990