Provider Demographics
NPI:1841822004
Name:DEGEN, REVEL SANDREL (CNP)
Entity type:Individual
Prefix:
First Name:REVEL
Middle Name:SANDREL
Last Name:DEGEN
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 1:910 W HAVENS AVE
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-3831
Mailing Address - Country:US
Mailing Address - Phone:605-996-9686
Mailing Address - Fax:
Practice Address - Street 1:117 S SPRING ST
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:MN
Practice Address - Zip Code:56156-1916
Practice Address - Country:US
Practice Address - Phone:507-283-9511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001721363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7311OtherMN BOARD OF NURSING