Provider Demographics
NPI:1730465360
Name:REVAY, CHARLIE LEE
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:LEE
Last Name:REVAY
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 1:6550 STATE ROAD 13 N
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2020
Mailing Address - Country:US
Mailing Address - Phone:904-563-6716
Mailing Address - Fax:
Practice Address - Street 1:6550 STATE ROAD 13 N
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-2020
Practice Address - Country:US
Practice Address - Phone:904-563-6716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 58964172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker