Provider Demographics
NPI:1225580293
Name:MODISETTE, RAVEN (FNP-C,PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:RAVEN
Middle Name:
Last Name:MODISETTE
Suffix:
Gender:F
Credentials:FNP-C,PMHNP-BC
Other - Prefix:MS
Other - First Name:RAVEN
Other - Middle Name:
Other - Last Name:MODISETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C, PMHNP-BC
Mailing Address - Street 1:3901 ARLINGTON HIGHLANDS BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76018-6050
Mailing Address - Country:US
Mailing Address - Phone:817-695-5035
Mailing Address - Fax:817-695-5037
Practice Address - Street 1:3901 ARLINGTON HIGHLANDS BLVD
Practice Address - Street 2:STE 200
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-6050
Practice Address - Country:US
Practice Address - Phone:817-695-5035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137299363LF0000X, 363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner