Provider Demographics
NPI:1275846420
Name:REILLO, MICHELLE RENEE (RN, NP, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENEE
Last Name:REILLO
Suffix:
Gender:F
Credentials:RN, NP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:129 SEAGROVE MAIN STREET
Mailing Address - Street 2:UNIT 202
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080
Mailing Address - Country:US
Mailing Address - Phone:804-296-4094
Mailing Address - Fax:904-217-0153
Practice Address - Street 1:129 SEAGROVE MAIN STREET
Practice Address - Street 2:202
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080
Practice Address - Country:US
Practice Address - Phone:804-296-4094
Practice Address - Fax:904-217-0153
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDR080304163WC0200X
FLRN 9303002261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical