Healthcare Provider Details

I. General information

NPI: 1508221870
Provider Name (Legal Business Name): SANDRA REVAK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 HURFFVILLE CROSSKEYS RD SUITE 160
SEWELL NJ
08080-4002
US

IV. Provider business mailing address

239 HURFFVILLE CROSSKEYS RD STE 160
SEWELL NJ
08080-4005
US

V. Phone/Fax

Practice location:
  • Phone: 856-341-8200
  • Fax: 856-341-8212
Mailing address:
  • Phone: 856-341-8200
  • Fax: 856-341-8215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00629600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR15492200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: