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General NPI Number Information
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NPI Number | 1235046392
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Entity Type | Organization
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Legal Business Name | REVOLUTION WELLNESS NP IN ADULT HEALTH PLLC
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Dates
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Enumeration Date | 08/25/2026
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Last Update Date | 08/25/2026
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Provider Practice Location Address
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Address Line | 296 S BICYCLE PATH
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City | FARMINGVILLE
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State | NY
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Zip | 11738-2124
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Country | US
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Telephone | 631-997-8799
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Fax |
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Provider Business Mailing Address
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Address Line | 121 MAIN ST # 1007
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City | NORTHPORT
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State | NY
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Zip | 11768-1721
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Country | US
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Telephone | 631-997-8799
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Fax | 209-589-0420
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Authorized Official
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Title or Position | OWNER
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Name | JELISA DOPWELL
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Credential | DNP
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Telephone | 631-997-8799
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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