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NPI Code Detail

MEDICARE: REVEL SANDREL DEGEN CNP

MEDICARE: REVEL SANDREL DEGEN CNP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse PractitionerCP001721SD

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17311OTHERMNMN BOARD OF NURSING

General Provider Information

NPI Number : 1841822004
Entity Type Code : Individual
Provider Name (Legal Business Name) : REVEL SANDREL DEGEN CNP
Provider Business Mailing Address
First Line : 910 W HAVENS AVE
Second Line :
City : MITCHELL
State : SD
Zip : 57301-3831
Country : US
Telephone Number : 605-996-9686
Fax Number :
Provider Business Practice Location Address
First Line : 117 S SPRING ST
Second Line :
City : LUVERNE
State : MN
Zip : 56156-1916
Country : US
Telephone Number : 507-283-9511
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/06/2020
Last Update Date : 12/02/2020

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Directions to “ REVEL SANDREL DEGEN CNP” Practice Location

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