Provider Demographics
NPI:1891789624
Name:RAVENELL, DIANNA D (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANNA
Middle Name:D
Last Name:RAVENELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 620
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6845
Practice Address - Country:US
Practice Address - Phone:803-779-6776
Practice Address - Fax:803-779-7346
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC28087207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC280877Medicaid