MEDICARE: MS. PETAGAYE LATOYA REYES PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	RN553029	PA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	SP027047	PA

General Provider Information

NPI Number	:	1508563479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PETAGAYE LATOYA REYES PMHNP-BC

Provider Business Mailing Address
First Line	:	9150 MARSHALL ST STE 14
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-2217
Country	:	US
Telephone Number	:	215-539-2470
Fax Number	:	215-240-6328

Provider Business Practice Location Address
First Line	:	9150 MARSHALL ST STE 14
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19114-2217
Country	:	US
Telephone Number	:	215-539-2470
Fax Number	:	215-539-2470

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2023
Last Update Date	:	04/01/2026

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