MEDICARE: RAVEN J'NAE BARLESTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	164.011805	IL

General Provider Information

NPI Number	:	1154124832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAVEN J'NAE BARLESTON

Provider Business Mailing Address
First Line	:	1449 N ASHLAND AVE APT 1R
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2269
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2924 W MEDILL AVE APT 509
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-0688
Country	:	US
Telephone Number	:	859-536-8471
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2025
Last Update Date	:	03/28/2025

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