Provider Demographics
NPI:1811753460
Name:REAVIS, REBEL MARY (FNP-C)
Entity type:Individual
Prefix:MS
First Name:REBEL
Middle Name:MARY
Last Name:REAVIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 W COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5211
Mailing Address - Country:US
Mailing Address - Phone:575-624-4922
Mailing Address - Fax:575-624-4902
Practice Address - Street 1:603 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5211
Practice Address - Country:US
Practice Address - Phone:575-624-4922
Practice Address - Fax:575-624-4902
Is Sole Proprietor?:No
Enumeration Date:2024-02-22
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77896363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty