Provider Demographics
NPI:1609536317
Name:RUSS, REVA MICHELLE (FNP)
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:MICHELLE
Last Name:RUSS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:REVA
Other - Middle Name:MICHELLE
Other - Last Name:RODAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 PALM HARBOR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1930
Mailing Address - Country:US
Mailing Address - Phone:727-474-0090
Mailing Address - Fax:727-474-0055
Practice Address - Street 1:445 CHARLES H DIMMOCK PKWY STE 101
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2990
Practice Address - Country:US
Practice Address - Phone:804-481-9400
Practice Address - Fax:804-481-9344
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024183254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily