Provider Demographics
NPI:1134323959
Name:REVETTE, VERONICA JOYCE (NP)
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:JOYCE
Last Name:REVETTE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43 WEBER RD
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-2109
Mailing Address - Country:US
Mailing Address - Phone:315-435-3240
Mailing Address - Fax:315-435-3884
Practice Address - Street 1:421 MONTGOMERY ST
Practice Address - Street 2:BASEMENT ROOM 80
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2923
Practice Address - Country:US
Practice Address - Phone:315-435-3240
Practice Address - Fax:315-435-3884
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300043-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health