Healthcare Provider Details

I. General information

NPI: 1831753334
Provider Name (Legal Business Name): BAO REARDON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 INDEPENDENCE CIR
VIRGINIA BEACH VA
23455-6405
US

IV. Provider business mailing address

500 KIRTS BLVD STE 100
TROY MI
48084-4135
US

V. Phone/Fax

Practice location:
  • Phone: 757-460-6080
  • Fax:
Mailing address:
  • Phone: 248-434-6169
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number101840471
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174847
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: