| Doctor Name: | RENE L. REVELLE |
| NPI Number: | 1639584139 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CNP |
| License Number: | COA15919NP |
| Business Practice Address: | 304a E 4th St Eldon, MO - 650261808 |
| Business Phone Number: | 5735572400 |
| Business Fax Number: | 5735572401 |
| Mailing Address: | Po Box 1500, OSAGE BEACH |
| State: | MO |
| Postal Code: | 650651500 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 06/24/2014 |
| NPI Last Update Date: | 06/29/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | COA15919NP |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | OH |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |