Provider Demographics
NPI:1821470238
Name:NIX, RAVEN L (NP-C)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:L
Last Name:NIX
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:L
Other - Last Name:COVERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 ESKENAZI AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5187
Practice Address - Country:US
Practice Address - Phone:317-880-7666
Practice Address - Fax:317-880-0448
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28184480A363L00000X
IN71005555A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201306800Medicaid
IN264431068OtherMEDICARE