Provider Demographics
NPI:1265290837
Name:EBANEZ, RAVEN (APRN-CNP)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:EBANEZ
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 N 1ST E
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1326
Mailing Address - Country:US
Mailing Address - Phone:208-852-4100
Mailing Address - Fax:
Practice Address - Street 1:44 N 1ST E
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1326
Practice Address - Country:US
Practice Address - Phone:208-852-2900
Practice Address - Fax:208-852-3511
Is Sole Proprietor?:No
Enumeration Date:2024-03-08
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID59770207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine