Provider Demographics
NPI:1407278757
Name:ENNIS, RAVEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:ENNIS
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 1:4270 S DECATUR BLVD STE B6
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-6802
Mailing Address - Country:US
Mailing Address - Phone:702-485-2100
Mailing Address - Fax:702-825-0091
Practice Address - Street 1:4270 S DECATUR BLVD STE B6
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-6802
Practice Address - Country:US
Practice Address - Phone:702-485-2100
Practice Address - Fax:702-825-0091
Is Sole Proprietor?:No
Enumeration Date:2014-01-06
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN73437163W00000X
NVAPRN002372363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse