Provider Demographics
NPI:1225710973
Name:FORD, RAVEN (CPM, LM)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:RAYA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPM, LM
Mailing Address - Street 1:405 FRANKFORT AVE
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7756
Mailing Address - Country:US
Mailing Address - Phone:206-476-6035
Mailing Address - Fax:
Practice Address - Street 1:405 FRANKFORT AVE
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7756
Practice Address - Country:US
Practice Address - Phone:206-476-6035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
WI522-49176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No174N00000XOther Service ProvidersLactation Consultant, Non-RN