Provider Demographics
NPI:1689008047
Name:FOSTER, RAVEN MICHELLE
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:MICHELLE
Last Name:FOSTER
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 1:3085 S JONES BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6782
Mailing Address - Country:US
Mailing Address - Phone:702-461-0608
Mailing Address - Fax:
Practice Address - Street 1:3085 S JONES BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6782
Practice Address - Country:US
Practice Address - Phone:702-461-0608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner