Provider Demographics
NPI:1174362974
Name:REVOLVE WELLNESS HUB LLC
Entity type:Organization
Organization Name:REVOLVE WELLNESS HUB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNP-PMH
Authorized Official - Prefix:
Authorized Official - First Name:UZOAMAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:MBADUGHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-201-6063
Mailing Address - Street 1:9858 BALE CT
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-6386
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9858 BALE CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-6386
Practice Address - Country:US
Practice Address - Phone:443-201-6063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty