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General NPI Number Information
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NPI Number | 1700377876
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Entity Type | Organization
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Legal Business Name | REVERED-HOLISTIC HEALTHCARE LLC
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Dates
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Enumeration Date | 05/24/2018
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 9861 BROKEN LAND PKWY STE 100
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City | COLUMBIA
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State | MD
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Zip | 21046-3031
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Country | US
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Telephone | 443-621-2203
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Fax | 410-381-0216
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Provider Business Mailing Address
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Address Line | 4218 SUMMER SHADE WAY
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City | OWINGS MILLS
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State | MD
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Zip | 21117-4872
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Country | US
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Telephone | 443-621-2203
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ADETUTU AWODIPE
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Credential | FNP
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Telephone | 443-621-2203
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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 | R194691
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License Number State | MD
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