Provider Demographics
NPI:1982374187
Name:BOUTTE, RAVEN
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:BOUTTE
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 1:100 MCDONALD ST APT D17
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506
Mailing Address - Country:US
Mailing Address - Phone:337-458-3835
Mailing Address - Fax:
Practice Address - Street 1:4510 AMBASSADOR CAFFERY PKWAY
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508
Practice Address - Country:US
Practice Address - Phone:337-458-3835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-18
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1003007207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Single Specialty