Provider Demographics
NPI:1508434366
Name:ROBERTS, RAVEN (NP)
Entity Type:Individual
Prefix:MS
First Name:RAVEN
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 CROWNE RESERVE DR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-7042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1575 MONTGOMERY HWY
Practice Address - Street 2:
Practice Address - City:VESTAVIA HILLS
Practice Address - State:AL
Practice Address - Zip Code:35216-4510
Practice Address - Country:US
Practice Address - Phone:205-822-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-166339363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care