MEDICARE: CARRIE JONES REVARD LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	0002031086	VA

General Provider Information

NPI Number	:	1508345802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE JONES REVARD LPN

Provider Business Mailing Address
First Line	:	7619 LITTLE RIVER TPKE STE 600
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-2628
Country	:	US
Telephone Number	:	703-752-8741
Fax Number	:	703-752-8746

Provider Business Practice Location Address
First Line	:	7619 LITTLE RIVER TPKE STE 600
Second Line	:
City	:	ANNANDALE
State	:	VA
Zip	:	22003-2628
Country	:	US
Telephone Number	:	703-752-8741
Fax Number	:	703-752-8746

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2018
Last Update Date	:	08/08/2018

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