Healthcare Provider Details

I. General information

NPI: 1720500952
Provider Name (Legal Business Name): KELLEY REVELS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

IV. Provider business mailing address

2429 S PRAIRIE AVE
PUEBLO CO
81005-2886
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-5070
  • Fax: 719-896-2874
Mailing address:
  • Phone: 719-564-5070
  • Fax: 719-896-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.1616979
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: