Healthcare Provider Details

I. General information

NPI: 1750374336
Provider Name (Legal Business Name): CATHERINE W REAVIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2005
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 R T STANLEY SR PL
LYONS GA
30436
US

IV. Provider business mailing address

110 R T STANLEY SR PL
LYONS GA
30436
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-9355
  • Fax: 912-526-4783
Mailing address:
  • Phone: 912-526-9355
  • Fax: 912-526-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN155029 NP
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP108269
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: