Healthcare Provider Details

I. General information

NPI: 1164945366
Provider Name (Legal Business Name): JANET LEE REVELLE AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 09/12/2025
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 CHRIS GAUPP DR
GALLOWAY NJ
08205-4487
US

IV. Provider business mailing address

3600 ROUTE 3RD FLOOR
NEPTUNE NJ
07753
US

V. Phone/Fax

Practice location:
  • Phone: 609-748-5370
  • Fax: 609-748-6870
Mailing address:
  • Phone: 732-807-0800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number41YA00010900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: