Healthcare Provider Details

I. General information

NPI: 1770768848
Provider Name (Legal Business Name): CHERIAL LASHAWN REVELL NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6801 RIVER RD SUITE 106
COLUMBUS GA
31904-3352
US

IV. Provider business mailing address

7982 NATURE TRL
COLUMBUS GA
31904-2156
US

V. Phone/Fax

Practice location:
  • Phone: 706-566-4288
  • Fax:
Mailing address:
  • Phone: 706-761-1661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN127665
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN127665
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN127665
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: