Provider Demographics
NPI:1255106423
Name:VILLANUEVA, RAYMUND BLACK (RN)
Entity type:Individual
Prefix:
First Name:RAYMUND
Middle Name:BLACK
Last Name:VILLANUEVA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 SPRING CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7700
Mailing Address - Country:US
Mailing Address - Phone:916-602-9009
Mailing Address - Fax:
Practice Address - Street 1:4441 E KINGS CANYON RD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-600-9180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-17
Last Update Date:2024-10-22
Deactivation Date:2024-02-22
Deactivation Code:
Reactivation Date:2024-10-22
Provider Licenses
StateLicense IDTaxonomies
CA95250016163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse