Provider Demographics
NPI:1669955019
Name:CUSTALOW, RAVEN (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:CUSTALOW
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3944 UPSHAW RD
Mailing Address - Street 2:
Mailing Address - City:AYLETT
Mailing Address - State:VA
Mailing Address - Zip Code:23009-2912
Mailing Address - Country:US
Mailing Address - Phone:804-928-8477
Mailing Address - Fax:
Practice Address - Street 1:7864 RICHMOND TAPPAHANNOCK HWY
Practice Address - Street 2:
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-3056
Practice Address - Country:US
Practice Address - Phone:804-769-2015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176579363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3001529971Medicaid