Healthcare Provider Details

I. General information

NPI: 1053479733
Provider Name (Legal Business Name): LYNNE K REVENO RN CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W FOSTER ST
MELROSE MA
02176-3810
US

IV. Provider business mailing address

8 MEADOWVIEW RD
MELROSE MA
02176-2913
US

V. Phone/Fax

Practice location:
  • Phone: 617-957-7944
  • Fax: 781-665-7543
Mailing address:
  • Phone: 617-957-7944
  • Fax: 781-665-7543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number101852
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: