Provider Demographics
NPI:1346704673
Name:SMITH, RAVEN JOSHLYN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:JOSHLYN
Last Name:SMITH
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 1:2340 BENNETT SPRINGS DR APT 107
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5383
Mailing Address - Country:US
Mailing Address - Phone:708-351-5335
Mailing Address - Fax:
Practice Address - Street 1:2340 BENNETT SPRINGS DR APT 107
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5383
Practice Address - Country:US
Practice Address - Phone:708-351-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer