Provider Demographics
NPI:1659102135
Name:REVILL-ALLEN, MARY LEE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:REVILL-ALLEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 VAN VORST ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5729
Mailing Address - Country:US
Mailing Address - Phone:315-886-0094
Mailing Address - Fax:
Practice Address - Street 1:40 VAN VORST ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5729
Practice Address - Country:US
Practice Address - Phone:315-886-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309041-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse