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General NPI Number Information
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NPI Number | 1851126932
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Entity Type | Organization
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Legal Business Name | AGELESS REWIND LLC
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Dates
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Enumeration Date | 09/06/2024
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Last Update Date | 03/13/2025
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Provider Practice Location Address
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Address Line | 1911 BLUE RIVER RD
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City | HOLIDAY
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State | FL
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Zip | 34691-7849
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Country | US
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Telephone | 727-320-7313
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Fax |
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Provider Business Mailing Address
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Address Line | 1911 BLUE RIVER RD
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City | HOLIDAY
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State | FL
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Zip | 34691-7849
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Country | US
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Telephone | 813-360-1806
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | KELLI WRAZIEN
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Credential | AGNP
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Telephone | 813-460-6440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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