Healthcare Provider Details

I. General information

NPI: 1932088440
Provider Name (Legal Business Name): RESURGENCE VITALITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 FAIRFAX DR STE 100
EDMOND OK
73034-3521
US

IV. Provider business mailing address

2901 FAIRFAX DR STE 100
EDMOND OK
73034-3521
US

V. Phone/Fax

Practice location:
  • Phone: 405-216-3437
  • Fax: 866-497-6393
Mailing address:
  • Phone: 405-216-3437
  • Fax: 405-645-7885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELA C. BAUSTERT
Title or Position: OWNER/NURSE PRACTITIONER
Credential: DNP, APRN, FNP-C
Phone: 405-216-3437