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General NPI Number Information
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NPI Number | 1063000479
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Entity Type | Organization
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Legal Business Name | REJUVENATED HEALTH & WELLNESS
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Dates
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Enumeration Date | 01/02/2021
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Last Update Date | 07/06/2022
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Provider Practice Location Address
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Address Line | 5221 S HIGHWAY 95 STE 13
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City | FORT MOHAVE
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State | AZ
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Zip | 86426-9244
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Country | US
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Telephone | 928-234-7572
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10837
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City | FORT MOHAVE
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State | AZ
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Zip | 86427-0837
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Country | US
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Telephone | 928-201-8289
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Fax |
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Authorized Official
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Title or Position | FNP-BC
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Name | DAYNA BLAKE
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Credential |
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Telephone | 928-201-8289
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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