Provider Demographics
NPI:1467967687
Name:PEW, RAVEN SIMONE (RN)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:SIMONE
Last Name:PEW
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:
Other - Last Name:TRICKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2737 YOUNGSTOWN RD SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-5002
Mailing Address - Country:US
Mailing Address - Phone:330-369-8022
Mailing Address - Fax:
Practice Address - Street 1:2737 YOUNGSTOWN RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-5002
Practice Address - Country:US
Practice Address - Phone:330-369-8022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166401164W00000X
OH506589163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse