Healthcare Provider Details

I. General information

NPI: 1649940198
Provider Name (Legal Business Name): JENNA REVELLE THOMAS ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 SOUTH BLVD E STE 190
ROCHESTER HILLS MI
48307-6124
US

IV. Provider business mailing address

1701 SOUTH BLVD E STE 190
ROCHESTER HILLS MI
48307-6124
US

V. Phone/Fax

Practice location:
  • Phone: 248-289-1509
  • Fax:
Mailing address:
  • Phone: 248-289-1509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704273322
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: