Provider Demographics
NPI:1457826042
Name:REVOREDO, LORENA FERNANDES (APRN)
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:FERNANDES
Last Name:REVOREDO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LORENA
Other - Middle Name:
Other - Last Name:WAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9290 LEGARE ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-5905
Mailing Address - Country:US
Mailing Address - Phone:561-221-5189
Mailing Address - Fax:
Practice Address - Street 1:5631 TELEPHONE RD STE B
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77087-4485
Practice Address - Country:US
Practice Address - Phone:281-727-0332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9259079363L00000X, 363LA2200X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care