Provider Demographics
NPI:1740549781
Name:LADNER, RAVEN SUZANNE (MD)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:SUZANNE
Last Name:LADNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:7275 S SIWELL RD
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-9767
Practice Address - Country:US
Practice Address - Phone:601-373-7722
Practice Address - Fax:601-373-7378
Is Sole Proprietor?:No
Enumeration Date:2012-05-11
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS23900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine