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General NPI Number Information
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NPI Number | 1457203879
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Entity Type | Organization
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Legal Business Name | REVIVE PRIMARY CARE AND MEDSPA PLLC
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Dates
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Enumeration Date | 02/10/2026
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Last Update Date | 02/10/2026
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Provider Practice Location Address
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Address Line | 2221 JACKSBORO PIKE STE A18
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City | LA FOLLETTE
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State | TN
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Zip | 37766-3035
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Country | US
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Telephone | 937-408-7606
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Fax | 865-332-1923
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Provider Business Mailing Address
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Address Line | 2221 JACKSBORO PIKE STE A18
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City | LA FOLLETTE
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State | TN
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Zip | 37766-3035
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Country | US
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Telephone | 937-408-7606
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Fax | 865-332-1923
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Authorized Official
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Title or Position | AGNP-CB
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Name | HEIDI M MARLOW
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Credential | NURSE PRACTITIONER
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Telephone | 937-408-7606
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State |
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