Provider Demographics
NPI:1083239719
Name:REVELS, ANN MARIE (RN)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:REVELS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3009
Mailing Address - Country:US
Mailing Address - Phone:503-380-2254
Mailing Address - Fax:
Practice Address - Street 1:1004 E 13TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3009
Practice Address - Country:US
Practice Address - Phone:503-380-2254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200341288163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management