Provider Demographics
NPI:1821799586
Name:REVELLE, WHITNEY MARIE
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:MARIE
Last Name:REVELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2281 LANIER RD
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001-4958
Mailing Address - Country:US
Mailing Address - Phone:731-345-0178
Mailing Address - Fax:
Practice Address - Street 1:TENNESSEE STATE VETERAN'S HOME
Practice Address - Street 2:2865 E. MAIN ST.
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343
Practice Address - Country:US
Practice Address - Phone:731-784-8405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13005048224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant