Healthcare Provider Details

I. General information

NPI: 1275846420
Provider Name (Legal Business Name): MICHELLE RENEE REILLO RN, NP, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 SEAGROVE MAIN STREET 202
ST. AUGUSTINE FL
32080
US

IV. Provider business mailing address

129 SEAGROVE MAIN STREET UNIT 202
ST. AUGUSTINE FL
32080
US

V. Phone/Fax

Practice location:
  • Phone: 804-296-4094
  • Fax: 904-217-0153
Mailing address:
  • Phone: 804-296-4094
  • Fax: 904-217-0153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR080304
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberRN 9303002
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: