Provider Demographics
NPI:1609536317
Name:RUSS, REVA MICHELLE (FNP)
Entity type:Individual
Prefix:
First Name:REVA
Middle Name:MICHELLE
Last Name:RUSS
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:REVA
Other - Middle Name:MICHELLE
Other - Last Name:RODAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 MOORE AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1311
Mailing Address - Country:US
Mailing Address - Phone:048-475-2858
Mailing Address - Fax:
Practice Address - Street 1:5855 BREMO RD STE 706
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1926
Practice Address - Country:US
Practice Address - Phone:804-287-4528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-21
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024183254363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily