Provider Demographics
NPI:1740887728
Name:GUTHRIE, REVELYN
Entity type:Individual
Prefix:
First Name:REVELYN
Middle Name:
Last Name:GUTHRIE
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 1:2165 KINGSFORD DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-2734
Mailing Address - Country:US
Mailing Address - Phone:314-283-3394
Mailing Address - Fax:
Practice Address - Street 1:2165 KINGSFORD DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-2734
Practice Address - Country:US
Practice Address - Phone:314-283-3394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-03
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO85-3277704Medicaid