Healthcare Provider Details

I. General information

NPI: 1992327217
Provider Name (Legal Business Name): KRISTINA REAVIS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 05/08/2020
Certification Date: 05/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 16TH ST
PUEBLO CO
81003-2781
US

IV. Provider business mailing address

312 MICHIGAN AVE
MANITOU SPRINGS CO
80829-1637
US

V. Phone/Fax

Practice location:
  • Phone: 719-659-8141
  • Fax:
Mailing address:
  • Phone: 719-659-8141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number995088
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number995088
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: