Provider Demographics
NPI:1639705361
Name:OTEY, REVA
Entity Type:Individual
Prefix:
First Name:REVA
Middle Name:
Last Name:OTEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4964 THORNSPRING RD
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-7022
Mailing Address - Country:US
Mailing Address - Phone:540-994-9598
Mailing Address - Fax:
Practice Address - Street 1:4964 THORNSPRING RD
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-7022
Practice Address - Country:US
Practice Address - Phone:540-994-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-13
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA11029237343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)