Provider Demographics
NPI:1790457497
Name:ROGGENBUCK, RAVEN LYNN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:LYNN
Last Name:ROGGENBUCK
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 1:3810 W 79TH AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-4321
Mailing Address - Country:US
Mailing Address - Phone:907-764-4164
Mailing Address - Fax:
Practice Address - Street 1:8130 OLD SEWARD HWY STE 103
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-3349
Practice Address - Country:US
Practice Address - Phone:907-522-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK156937225700000X
AK156537225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist