Provider Demographics
NPI:1164099412
Name:REVILLAS, AMBROCIA LOURDES
Entity Type:Individual
Prefix:
First Name:AMBROCIA
Middle Name:LOURDES
Last Name:REVILLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:REVILLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LVN
Mailing Address - Street 1:427 PAJARO ST STE 456
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-3459
Mailing Address - Country:US
Mailing Address - Phone:831-424-6655
Mailing Address - Fax:
Practice Address - Street 1:427 PAJARO ST STE 4
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3459
Practice Address - Country:US
Practice Address - Phone:831-424-6655
Practice Address - Fax:831-424-9717
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251187164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse