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General NPI Number Information
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NPI Number | 1265124846
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Entity Type | Organization
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Legal Business Name | REVELATIONS RX PLLC
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Dates
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Enumeration Date | 05/23/2023
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Last Update Date | 11/07/2023
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Provider Practice Location Address
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Address Line | 640 N RIVER RD STE 108
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City | NAPERVILLE
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State | IL
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Zip | 60563-8947
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Country | US
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Telephone | 630-858-0875
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Fax |
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Provider Business Mailing Address
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Address Line | 174 S MONTCLAIR AVE
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City | GLEN ELLYN
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State | IL
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Zip | 60137-6357
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Country | US
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Telephone | 630-858-0875
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Fax |
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Authorized Official
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Title or Position | MEMBER/OWNER
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Name | DORIS VAN BYSSUM
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Credential |
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Telephone | 630-858-0875
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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