Healthcare Provider Details

I. General information

NPI: 1548174626
Provider Name (Legal Business Name): JOAN MUSIIMENTA REVELES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 BROOKE AVE APT 510
NORFOLK VA
23510-1844
US

IV. Provider business mailing address

130 BROOKE AVE APT 510
NORFOLK VA
23510-1844
US

V. Phone/Fax

Practice location:
  • Phone: 512-949-1083
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: