Provider Demographics
NPI:1639584139
Name:REVELLE, RENE L (CNP)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:L
Last Name:REVELLE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1500
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304A E 4TH ST
Practice Address - Street 2:
Practice Address - City:ELDON
Practice Address - State:MO
Practice Address - Zip Code:65026-1808
Practice Address - Country:US
Practice Address - Phone:573-557-2400
Practice Address - Fax:573-557-2401
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA15919NP363LF0000X
MO2015010647363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0105747Medicaid
WV3810027971Medicaid
OH0105747Medicaid