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General NPI Number Information
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NPI Number | 1124809801
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Entity Type | Organization
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Legal Business Name | LIFTUP LIVEWELL LLC
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Dates
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Enumeration Date | 10/10/2023
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Last Update Date | 11/29/2023
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Provider Practice Location Address
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Address Line | 111 TOWN SQUARE PL STE 803054
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City | JERSEY CITY
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State | NJ
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Zip | 07310-1755
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Country | US
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Telephone | 212-918-4488
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Fax |
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Provider Business Mailing Address
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Address Line | 111 TOWN SQUARE PL STE 803054
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City | JERSEY CITY
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State | NJ
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Zip | 07310-1755
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Country | US
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Telephone | 212-918-4488
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NERISA BRYAN
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Credential | APN
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Telephone | 212-918-4488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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