Jacqueline Revello, MA, RN
Individual provider Active NPI Registered Nurse · Divide, CO
NPI 1003084369 · NPPES record last updated Feb 10, 2017
Key facts
- NPI
- 1003084369
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Registered Nurse 163W00000X
- License
- RN0188325 (CO)
- Practice address
- 11115 W. Hwy 24, Unit 2C
Divide, CO 80814 - Phone
- (719) 687-6416
- NPI assigned
- Feb 20, 2008
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Master of Arts, Registered Nurse
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RN0188325 | CO | MD | Registered Nurse |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Teller County | Past | Accepting new patients | |
| Teller County Public Health | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Counselor | 101Y00000X | |||
| Registered Nurse | 163W00000X | RN0188325 | CO | Yes |
Addresses
Primary practice location
11115 W. Hwy 24, Unit 2C
Divide, CO 80814
Mailing address
PO Box 214
682 Simba Point
Divide, CO 80814-0214
Phone (719) 687-4224
Other names
- Ms. Jacqueline Davis
Other providers in Divide, CO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 10, 2017. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.