=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760804546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE EVANS-REAVIS NP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2014
-----------------------------------------------------
Last Update Date | 08/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13551 WATERFORD PL
-----------------------------------------------------
City | MIDLOTHIAN
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23112-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-320-4243
-----------------------------------------------------
Fax | 804-622-0552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 BOULDERS PKWY SUITE 102
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23225-5545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-320-4243
-----------------------------------------------------
Fax | 804-622-0552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 26NJ00439500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 0024171909
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------