Provider Demographics
NPI:1720554629
Name:BASSETT, RAVEN NICOLE
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:NICOLE
Last Name:BASSETT
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 1:331 SE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-2224
Mailing Address - Country:US
Mailing Address - Phone:541-276-6207
Mailing Address - Fax:
Practice Address - Street 1:331 SE 2ND ST
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-2224
Practice Address - Country:US
Practice Address - Phone:541-276-6207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist