Provider Demographics
NPI:1295552172
Name:REYNOLDS, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:REYNOLDS
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 1:22620 EMERY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH RANDALL
Mailing Address - State:OH
Mailing Address - Zip Code:44128-4622
Mailing Address - Country:US
Mailing Address - Phone:330-774-2175
Mailing Address - Fax:
Practice Address - Street 1:22620 EMERY RD
Practice Address - Street 2:
Practice Address - City:NORTH RANDALL
Practice Address - State:OH
Practice Address - Zip Code:44128-4622
Practice Address - Country:US
Practice Address - Phone:330-774-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty