Provider Demographics
NPI:1417456203
Name:HEATHERLY, RAVEN MICHELLE (NP-C)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:MICHELLE
Last Name:HEATHERLY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 FORT SANDERS WEST BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-3355
Mailing Address - Country:US
Mailing Address - Phone:865-769-4500
Mailing Address - Fax:865-769-4501
Practice Address - Street 1:90 VERMONT AVE STE 300
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830
Practice Address - Country:US
Practice Address - Phone:865-481-2541
Practice Address - Fax:865-483-8151
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23818363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner