Provider Demographics
NPI:1639697741
Name:REVELL, KRISTINA MICHELLE
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MICHELLE
Last Name:REVELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MICHELLE
Other - Last Name:REVELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11552 NW SUMMERS RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-3344
Mailing Address - Country:US
Mailing Address - Phone:850-686-9764
Mailing Address - Fax:
Practice Address - Street 1:11552 NW SUMMERS RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-3344
Practice Address - Country:US
Practice Address - Phone:850-686-9764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9375914163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care