Healthcare Provider Details

I. General information

NPI: 1669745683
Provider Name (Legal Business Name): REVA SABRINA LYTTLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 KENTFIELD DR
DAYTON OH
45426-1853
US

IV. Provider business mailing address

4607 KENTFIELD DR
TROTWOOD OH
45426-1853
US

V. Phone/Fax

Practice location:
  • Phone: 937-837-2558
  • Fax:
Mailing address:
  • Phone: 937-837-2558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: