Healthcare Provider Details

I. General information

NPI: 1215442124
Provider Name (Legal Business Name): LAINA M REAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2017
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ROUTE 108
SOMERSWORTH NH
03878-1522
US

IV. Provider business mailing address

311 ROUTE 108
SOMERSWORTH NH
03878-1522
US

V. Phone/Fax

Practice location:
  • Phone: 603-749-2346
  • Fax: 603-953-0066
Mailing address:
  • Phone: 603-749-2346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number0013
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: