Healthcare Provider Details

I. General information

NPI: 1235843095
Provider Name (Legal Business Name): HEIDI SUE REVES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 GOLFVIEW AVE
BARTOW FL
33830-6736
US

IV. Provider business mailing address

1519 CORDGRASS WAY
LAKELAND FL
33813-2715
US

V. Phone/Fax

Practice location:
  • Phone: 863-519-5174
  • Fax:
Mailing address:
  • Phone: 863-512-4836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9263154
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: