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General NPI Number Information
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NPI Number | 1548940752
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Entity Type | Organization
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Legal Business Name | REVIVE WELLNESS AND AESTHETICS
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Dates
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Enumeration Date | 07/21/2023
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Last Update Date | 07/21/2023
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Provider Practice Location Address
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Address Line | 445 S FITNESS PL # 130
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City | EAGLE
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State | ID
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Zip | 83616-6828
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Country | US
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Telephone | 208-939-2332
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Fax |
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Provider Business Mailing Address
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Address Line | 4253 N SORREL PL
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City | BOISE
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State | ID
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Zip | 83703-3487
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/NURSE PRACTITIONER
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Name | KELSEY MARTIN
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Credential | DNP, FNP-C
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Telephone | 217-617-2575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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