Provider Demographics
NPI:1952143794
Name:REVILLA, REVILBRAY (FNP-C)
Entity type:Individual
Prefix:
First Name:REVILBRAY
Middle Name:
Last Name:REVILLA
Suffix:
Gender:M
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 1:6301 SW 150TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-2790
Mailing Address - Country:US
Mailing Address - Phone:786-395-6120
Mailing Address - Fax:
Practice Address - Street 1:6301 SW 150TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2790
Practice Address - Country:US
Practice Address - Phone:786-395-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11033303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily