Provider Demographics
NPI:1346869427
Name:SMITH, RAVEN L
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:L
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 1:201 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-2426
Mailing Address - Country:US
Mailing Address - Phone:478-552-3210
Mailing Address - Fax:478-553-1832
Practice Address - Street 1:201 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-2426
Practice Address - Country:US
Practice Address - Phone:478-552-3210
Practice Address - Fax:478-553-1832
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149626163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003257057AMedicaid