Healthcare Provider Details

I. General information

NPI: 1639584139
Provider Name (Legal Business Name): RENE L. REVELLE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304A E 4TH ST
ELDON MO
65026-1808
US

IV. Provider business mailing address

PO BOX 1500
OSAGE BEACH MO
65065-1500
US

V. Phone/Fax

Practice location:
  • Phone: 573-557-2400
  • Fax: 573-557-2401
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA15919NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015010647
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: