Provider Demographics
NPI:1689872566
Name:RAVEN, RACHEL I (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:I
Last Name:RAVEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:RACHEL
Other - Middle Name:IRENE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:50 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1786
Mailing Address - Country:US
Mailing Address - Phone:315-261-6034
Mailing Address - Fax:315-261-6025
Practice Address - Street 1:77 W. BARNEY ST.
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642
Practice Address - Country:US
Practice Address - Phone:315-261-5871
Practice Address - Fax:315-714-3068
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33-336822363LF0000X
NY2741741164W00000X
NY336822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No164W00000XNursing Service ProvidersLicensed Practical Nurse