Healthcare Provider Details

I. General information

NPI: 1336961655
Provider Name (Legal Business Name): TONYA EVETTE REVELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5034 ATLANTIC AVE
MAYS LANDING NJ
08330-2022
US

IV. Provider business mailing address

305 PICKWICK DR
WILLIAMSTOWN NJ
08094-1989
US

V. Phone/Fax

Practice location:
  • Phone: 609-782-0005
  • Fax:
Mailing address:
  • Phone: 609-481-1988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number26NR24248900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: