Provider Demographics
NPI:1609557404
Name:CHESTNUT, RAVIN LEMAR
Entity Type:Individual
Prefix:
First Name:RAVIN
Middle Name:LEMAR
Last Name:CHESTNUT
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 1:26166 REGENCY CLUB CIR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1699
Mailing Address - Country:US
Mailing Address - Phone:313-539-1449
Mailing Address - Fax:
Practice Address - Street 1:26166 REGENCY CLUB CIR UNIT 2
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1699
Practice Address - Country:US
Practice Address - Phone:313-539-1449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4703127340164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse