Provider Demographics
NPI:1932088440
Name:RESURGENCE VITALITY, LLC
Entity type:Organization
Organization Name:RESURGENCE VITALITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAUSTERT
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN
Authorized Official - Phone:405-216-3437
Mailing Address - Street 1:2901 FAIRFAX DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3521
Mailing Address - Country:US
Mailing Address - Phone:405-216-3437
Mailing Address - Fax:866-497-6393
Practice Address - Street 1:2901 FAIRFAX DR STE 100
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3521
Practice Address - Country:US
Practice Address - Phone:405-216-3437
Practice Address - Fax:866-497-6393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-28
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty