Provider Demographics
NPI:1689325144
Name:RAEVOURI, SOPHIA C
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:C
Last Name:RAEVOURI
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 1:9 VICOLO LOREN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-3193
Mailing Address - Country:US
Mailing Address - Phone:626-899-8567
Mailing Address - Fax:
Practice Address - Street 1:6926 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7254
Practice Address - Country:US
Practice Address - Phone:360-993-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61370244363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health