Provider Demographics
NPI:1508221870
Name:REVAK, SANDRA (FNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:REVAK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 HURFFVILLE CROSSKEYS RD STE 160
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-4005
Mailing Address - Country:US
Mailing Address - Phone:856-341-8200
Mailing Address - Fax:856-341-8215
Practice Address - Street 1:239 HURFFVILLE CROSSKEYS RD
Practice Address - Street 2:SUITE 160
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-4002
Practice Address - Country:US
Practice Address - Phone:856-341-8200
Practice Address - Fax:856-341-8212
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR15492200163W00000X
NJ26NJ00629600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse