Healthcare Provider Details

I. General information

NPI: 1841822004
Provider Name (Legal Business Name): REVEL SANDREL DEGEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S SPRING ST
LUVERNE MN
56156-1916
US

IV. Provider business mailing address

910 W HAVENS AVE
MITCHELL SD
57301-3831
US

V. Phone/Fax

Practice location:
  • Phone: 507-283-9511
  • Fax:
Mailing address:
  • Phone: 605-996-9686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCP001721
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: