Provider Demographics
NPI:1669745683
Name:LYTTLE, REVA SABRINA
Entity type:Individual
Prefix:
First Name:REVA
Middle Name:SABRINA
Last Name:LYTTLE
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 1:4607 KENTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-1853
Mailing Address - Country:US
Mailing Address - Phone:937-837-2558
Mailing Address - Fax:
Practice Address - Street 1:4607 KENTFIELD DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45426-1853
Practice Address - Country:US
Practice Address - Phone:937-837-2558
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1221TBMedicaid