Provider Demographics
NPI:1063875110
Name:REVELLO, MARY KATHRYN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:REVELLO
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 1:9322 GERALD DR
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-8314
Mailing Address - Country:US
Mailing Address - Phone:330-221-6022
Mailing Address - Fax:
Practice Address - Street 1:103 N.SCYCAMORE ST
Practice Address - Street 2:
Practice Address - City:RAVENNA 44266
Practice Address - State:OH
Practice Address - Zip Code:44266
Practice Address - Country:US
Practice Address - Phone:330-221-6022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide