Provider Demographics
NPI:1356731871
Name:WALRAVEN, MICHELLE (CPHT)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:WALRAVEN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S GATEWAY DR
Mailing Address - Street 2:T-2175
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-1228
Mailing Address - Country:US
Mailing Address - Phone:540-374-4821
Mailing Address - Fax:540-374-4831
Practice Address - Street 1:25 S GATEWAY DR
Practice Address - Street 2:T-2175
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22406-1228
Practice Address - Country:US
Practice Address - Phone:540-374-4821
Practice Address - Fax:540-374-4831
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230007988183700000X
VA290101040759955183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
290101040759955OtherPHARMACY TECHNICIAN CERTIFICATION BOARD
0230007988OtherCOMMONWEALTH OF VIRGINIA STATE LICENSE