Healthcare Provider Details

I. General information

NPI: 1558829721
Provider Name (Legal Business Name): RAVEN SHENETTE MAYES JAMES ONA/MD/ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RAVEN SHENETTE MAYES ARNP/MD/ARNP

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 E MARIPOSA AVE
EL SEGUNDO CA
90245-5029
US

IV. Provider business mailing address

PO BOX 2303
HAWTHORNE FL
32640-2303
US

V. Phone/Fax

Practice location:
  • Phone: 310-426-6000
  • Fax:
Mailing address:
  • Phone: 352-271-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number50-4007
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCEP15022
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberABNP1418
License Number StateAL
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberFLAPN559215
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number50-2560
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberONA21898
License Number StateMA
# 8
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberCNA92737
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberM200-737-79-557-0
License Number StateFL
# 10
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number50-2560
License Number StateFL
# 11
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number50-2560
License Number StateFL
# 12
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number7-0076
License Number StateKY
# 13
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number50-1454
License Number StateDC
# 14
Primary TaxonomyN
Taxonomy Code332100000X
TaxonomyDepartment of Veterans Affairs (VA) Pharmacy
License Number50-2560
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: