Provider Demographics
NPI:1932096674
Name:REVOLUTION LONGEVITY AND WELLNESS LLC
Entity type:Organization
Organization Name:REVOLUTION LONGEVITY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:603-793-5969
Mailing Address - Street 1:91 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-2468
Mailing Address - Country:US
Mailing Address - Phone:603-793-5969
Mailing Address - Fax:
Practice Address - Street 1:91 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-2468
Practice Address - Country:US
Practice Address - Phone:603-793-5969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty