Healthcare Provider Details

I. General information

NPI: 1528693181
Provider Name (Legal Business Name): RONELLE REVILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 9TH AVE
SEATTLE WA
98101-2756
US

IV. Provider business mailing address

1100 9TH AVE M4-PFS
SEATTLE WA
98101-2756
US

V. Phone/Fax

Practice location:
  • Phone: 206-341-0394
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61065135
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60560871
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: