Provider Demographics
NPI:1629439294
Name:RAVAL, EMILY ANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
Last Name:RAVAL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ANNE
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:904 N WAIOLA AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1454
Mailing Address - Country:US
Mailing Address - Phone:319-759-8088
Mailing Address - Fax:
Practice Address - Street 1:904 N WAIOLA AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1454
Practice Address - Country:US
Practice Address - Phone:319-759-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC109859367500000X
IL209020007367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered