Provider Demographics
NPI:1437907870
Name:REVELS, BROOKE LOGSDON (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:LOGSDON
Last Name:REVELS
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 1:555 NW LAKE WHITNEY PL STE 103
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1623
Mailing Address - Country:US
Mailing Address - Phone:772-468-0042
Mailing Address - Fax:
Practice Address - Street 1:555 NW LAKE WHITNEY PL STE 103
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1623
Practice Address - Country:US
Practice Address - Phone:772-468-0042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11033176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily