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General NPI Number Information
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NPI Number | 1902724776
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Entity Type | Organization
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Legal Business Name | REVIVEWAVE THERAPEUTICS LLC
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Dates
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Enumeration Date | 07/08/2026
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Last Update Date | 07/08/2026
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Provider Practice Location Address
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Address Line | 6399 GOODMAN RD STE 105
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-7063
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Country | US
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Telephone | 662-300-6822
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Fax |
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Provider Business Mailing Address
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Address Line | 6399 GOODMAN RD STE 105
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City | OLIVE BRANCH
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State | MS
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Zip | 38654-7063
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Country | US
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Telephone | 662-300-6822
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Fax |
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Authorized Official
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Title or Position | OWNER / FOUNDER
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Name | MR. JACK CHANDLER PAPA
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Credential | MSN, APRN, FNP-C
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Telephone | 662-300-6822
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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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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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