=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275846420
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE RENEE REILLO RN, NP, PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2010
-----------------------------------------------------
Last Update Date | 01/07/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 129 SEAGROVE MAIN STREET 202
-----------------------------------------------------
City | ST. AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-296-4094
-----------------------------------------------------
Fax | 904-217-0153
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 129 SEAGROVE MAIN STREET UNIT 202
-----------------------------------------------------
City | ST. AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-296-4094
-----------------------------------------------------
Fax | 904-217-0153
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | R080304
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | RN 9303002
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------