Provider Demographics
NPI:1750104345
Name:RAVENELL, KEYANA
Entity type:Individual
Prefix:
First Name:KEYANA
Middle Name:
Last Name:RAVENELL
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 1:155 CANAL LANDING BLVD APT 636
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-5118
Mailing Address - Country:US
Mailing Address - Phone:585-203-7497
Mailing Address - Fax:
Practice Address - Street 1:155 CANAL LANDING BLVD APT 636
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-5118
Practice Address - Country:US
Practice Address - Phone:585-203-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346516164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse