MEDICARE: REVOLVE WELLNESS HUB LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1174362974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REVOLVE WELLNESS HUB LLC

Provider Business Mailing Address
First Line	:	1190 WINTERSON RD STE 200
Second Line	:
City	:	LINTHICUM
State	:	MD
Zip	:	21090-2245
Country	:	US
Telephone Number	:	443-318-3289
Fax Number	:	443-788-1787

Provider Business Practice Location Address
First Line	:	1190 WINTERSON RD STE 200
Second Line	:
City	:	LINTHICUM
State	:	MD
Zip	:	21090-2245
Country	:	US
Telephone Number	:	443-201-6063
Fax Number	:

Authorized Official
Title or Position	:	CRNP-PMH
Name	:	UZOAMAKA MBADUGHA
Credential	:
Telephone Number	:	443-201-6063

Provider Enumeration Date	:	05/21/2024
Last Update Date	:	04/20/2026

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