Provider Demographics
NPI:1417833856
Name:REJUVARIS
Entity type:Organization
Organization Name:REJUVARIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:ABISOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALADE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP,CRNP
Authorized Official - Phone:410-929-4790
Mailing Address - Street 1:9635 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2436
Mailing Address - Country:US
Mailing Address - Phone:410-929-4790
Mailing Address - Fax:
Practice Address - Street 1:9635 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2436
Practice Address - Country:US
Practice Address - Phone:410-929-4790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care