# REVIVE KETAMINE CLINIC, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1053984484
- **Authorized official:** DR. GINGER WILLIAMS DNP, CRNA (OWNER/PRACTITIONER)
- **Authorized official phone:** (901) 317-7900

## Contact information

- **Practice address:** 5820 STAGE RD, BARTLETT, TN 38134-4518
- **Practice address phone:** (901) 317-7900
- **Practice address fax:** (901) 317-7899
- **Mailing address:** 5820 STAGE RD, BARTLETT, TN 38134-4518
- **Mailing address phone:** (901) 317-7900
- **Mailing address fax:** (901) 317-7899

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QM2500X | Medical Specialty Clinic/Center | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 07/22/2021
- **Last updated:** 04/15/2024