Provider Demographics
NPI:1528566601
Name:MOSLEY, RAVEN NICOLE
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:NICOLE
Last Name:MOSLEY
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 1:2505 WASHINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-5210
Mailing Address - Country:US
Mailing Address - Phone:513-237-5096
Mailing Address - Fax:
Practice Address - Street 1:2505 WASHINGTON CIR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-5210
Practice Address - Country:US
Practice Address - Phone:513-237-5096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH132544164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000Medicaid
OH0000000Medicaid