Provider Demographics
NPI:1508576786
Name:BROADEN, RAVEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:BROADEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45964 BRENTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-5410
Mailing Address - Country:US
Mailing Address - Phone:912-308-0225
Mailing Address - Fax:
Practice Address - Street 1:45964 BRENTWOOD ST
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-5410
Practice Address - Country:US
Practice Address - Phone:912-308-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-29
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704306601163W00000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse