Provider Demographics
NPI:1760804546
Name:EVANS-REAVIS, MICHELE (NP-C)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:EVANS-REAVIS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BOULDERS PKWY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-5545
Mailing Address - Country:US
Mailing Address - Phone:804-320-4243
Mailing Address - Fax:804-622-0552
Practice Address - Street 1:13551 WATERFORD PL
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3929
Practice Address - Country:US
Practice Address - Phone:804-320-4243
Practice Address - Fax:804-622-0552
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00439500363LA2200X
VA0024171909363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherGROUP PTAN