Provider Demographics
NPI:1366887507
Name:REVELL, DEBORAH (NP)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:REVELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:M
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1683 BRONSON RD
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-3040
Mailing Address - Country:US
Mailing Address - Phone:330-958-2384
Mailing Address - Fax:330-249-7227
Practice Address - Street 1:1683 BRONSON RD
Practice Address - Street 2:
Practice Address - City:TALLMADGE
Practice Address - State:OH
Practice Address - Zip Code:44278-3040
Practice Address - Country:US
Practice Address - Phone:330-958-2384
Practice Address - Fax:330-249-7227
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2018-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA09984NP363LW0102X
OHCOA.09984-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083452Medicaid
OH0083452Medicaid