Provider Demographics
NPI:1124104831
Name:REVELLE, SARA (FNP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:REVELLE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:573-499-9009
Mailing Address - Fax:573-499-4400
Practice Address - Street 1:900 W NIFONG STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-3032
Practice Address - Country:US
Practice Address - Phone:573-499-9009
Practice Address - Fax:573-499-4400
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO096829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO096829OtherSTATE LICENSE
MOS28355Medicare UPIN