Provider Demographics
NPI:1710456314
Name:REVIEA, MARY (LVN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:REVIEA
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 S 13TH ST APT 625
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7815
Mailing Address - Country:US
Mailing Address - Phone:254-780-8763
Mailing Address - Fax:
Practice Address - Street 1:1700 S LAMAR BLVD
Practice Address - Street 2:BUILDING 1 SUITE 101
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-3360
Practice Address - Country:US
Practice Address - Phone:512-445-7787
Practice Address - Fax:512-440-4059
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX152486164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse