Healthcare Provider Details

I. General information

NPI: 1790143436
Provider Name (Legal Business Name): REVELSTONE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 CONCORD RD
ALBEMARLE NC
28001-4612
US

IV. Provider business mailing address

232 CONCORD RD
ALBEMARLE NC
28001-4612
US

V. Phone/Fax

Practice location:
  • Phone: 704-986-3900
  • Fax: 704-986-3913
Mailing address:
  • Phone: 704-986-3900
  • Fax: 704-986-3913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9400873
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. EDWARD ALLEN KEPP
Title or Position: OWNER
Credential: MD
Phone: 704-986-3900