Provider Demographics
NPI:1568977858
Name:REVIS, BONITA
Entity type:Individual
Prefix:
First Name:BONITA
Middle Name:
Last Name:REVIS
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 1:2325 SELMA AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1305
Mailing Address - Country:US
Mailing Address - Phone:850-851-7399
Mailing Address - Fax:
Practice Address - Street 1:2325 SELMA AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1305
Practice Address - Country:US
Practice Address - Phone:850-851-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401191400111374U00000X, 385H00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No385H00000XRespite Care FacilityRespite Care