=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861559825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REVIA MICHELLE VENEY CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 01/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 LOTTSFORD VISTA RD SKILLED NURSING FACILITY-
-----------------------------------------------------
City | MITCHELLVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20721-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-832-2095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17101 ASPEN LEAF DRIVE
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20716-3643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-464-2169
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN56198
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------