Provider Demographics
NPI:1205079456
Name:REVTA, BERNADETTE M (CNS)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:M
Last Name:REVTA
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18101 LORAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44111-5612
Mailing Address - Country:US
Mailing Address - Phone:216-476-7000
Mailing Address - Fax:
Practice Address - Street 1:18101 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5612
Practice Address - Country:US
Practice Address - Phone:440-879-0081
Practice Address - Fax:440-879-0084
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS-01712364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist