Revitalize IV Hydration and Wellness Clinc LLC

Primary specialty

Family Nurse PractitionerTaxonomy code 363LF0000X

Legal business name

REVITALIZE IV HYDRATION AND WELLNESS CLINC LLC

Practice address

2704 Phillips Dr Ste a
Jonesboro, AR 72401-7399

Phone

(870) 955-5701

Fax

(302) 209-5619

NPI assigned

Nov 28, 2023

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Felica Johnson, NURSE PRACTITIONERNPI 1881256220

Title

FNP

Phone

(870) 273-4164

Specialties & licenses 1

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Felica Shunta Johnson

  • Nurse Practitioner
  • West Memphis, AR
  • NPI 1881256220
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1701129600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701648000000",
    "number": "1871369272",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2704 PHILLIPS DR STE A",
            "city": "JONESBORO",
            "state": "AR",
            "postal_code": "724017399",
            "telephone_number": "870-955-5701",
            "fax_number": "302-209-5619"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2704 PHILLIPS DR STE A",
            "city": "JONESBORO",
            "state": "AR",
            "postal_code": "724017399",
            "telephone_number": "870-955-5701",
            "fax_number": "302-209-5619"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVITALIZE IV HYDRATION AND WELLNESS CLINC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-11-28",
        "last_updated": "2023-12-04",
        "certification_date": "2023-12-04",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "FELICA",
        "authorized_official_title_or_position": "FNP",
        "authorized_official_telephone_number": "870-273-4164",
        "authorized_official_credential": "NURSE PRACTITIONER"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.