Provider Demographics
NPI:1972075356
Name:REVAK, VICKI SUE (MSN, AGAC-BC)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:SUE
Last Name:REVAK
Suffix:
Gender:F
Credentials:MSN, AGAC-BC
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:SUE
Other - Last Name:KAISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10757 PONT RD
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:PA
Mailing Address - Zip Code:16401-8605
Mailing Address - Country:US
Mailing Address - Phone:814-336-4865
Mailing Address - Fax:
Practice Address - Street 1:680 BLAIR MILL RD
Practice Address - Street 2:
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-2223
Practice Address - Country:US
Practice Address - Phone:267-261-4413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-22
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP019667363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology