Healthcare Provider Details

I. General information

NPI: 1922968692
Provider Name (Legal Business Name): THE REVIVAL RESERVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 N FILLMORE ST APT 228
ARLINGTON VA
22201-6703
US

IV. Provider business mailing address

1025 N FILLMORE ST APT 228
ARLINGTON VA
22201-6703
US

V. Phone/Fax

Practice location:
  • Phone: 704-258-1453
  • Fax:
Mailing address:
  • Phone: 704-258-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: JESSICA KHARNAS
Title or Position: CO-OWNER
Credential:
Phone: 704-258-1453