Provider Demographics
NPI:1164416723
Name:REVELS, SELINA E (NP)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:E
Last Name:REVELS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0516
Mailing Address - Country:US
Mailing Address - Phone:912-785-7022
Mailing Address - Fax:912-705-8010
Practice Address - Street 1:275 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0516
Practice Address - Country:US
Practice Address - Phone:912-785-7022
Practice Address - Fax:912-705-8010
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN073465363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000965478AMedicaid
P61981Medicare UPIN
GA000965478AMedicaid