Provider Demographics
NPI:1164076733
Name:REAVES, AVIA LATRELLE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AVIA
Middle Name:LATRELLE
Last Name:REAVES
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 TAYLOR ST STE 8A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2955
Mailing Address - Country:US
Mailing Address - Phone:803-929-2955
Mailing Address - Fax:
Practice Address - Street 1:1301 TAYLOR ST STE 8A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-929-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23110363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily