Healthcare Provider Details

I. General information

NPI: 1164149621
Provider Name (Legal Business Name): MARY ANN REVELES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W THOUSAND OAKS BLVD STE A-2
THOUSAND OAKS CA
91360-4416
US

IV. Provider business mailing address

33 W THOUSAND OAKS BLVD STE A-2
THOUSAND OAKS CA
91360-4416
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-7888
  • Fax: 805-494-3498
Mailing address:
  • Phone: 805-497-7888
  • Fax: 805-494-3498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022758
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: