Provider Demographics
NPI:1407682107
Name:REVELS, NESHA
Entity type:Individual
Prefix:
First Name:NESHA
Middle Name:
Last Name:REVELS
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 1:7420 UNITY AVE N STE 312
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3136
Mailing Address - Country:US
Mailing Address - Phone:651-332-9100
Mailing Address - Fax:
Practice Address - Street 1:7420 UNITY AVE N STE 312
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3136
Practice Address - Country:US
Practice Address - Phone:651-332-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCFSSPCA1292848202408374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide