Provider Demographics
NPI:1659982098
Name:BROOMES, RAVONE
Entity Type:Individual
Prefix:
First Name:RAVONE
Middle Name:
Last Name:BROOMES
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 1:2402 DEAN ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11233-6750
Mailing Address - Country:US
Mailing Address - Phone:917-657-2617
Mailing Address - Fax:
Practice Address - Street 1:2402 DEAN ST APT 3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-6750
Practice Address - Country:US
Practice Address - Phone:917-657-2617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist