Healthcare Provider Details

I. General information

NPI: 1174167241
Provider Name (Legal Business Name): RAVEN MONIQUE HAWTHORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 03/06/2024
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 KINGS COUNTY DR STE 104106
HANFORD CA
93230-3579
US

IV. Provider business mailing address

530 KINGS COUNTY DR STE 104106
HANFORD CA
93230-3579
US

V. Phone/Fax

Practice location:
  • Phone: 559-754-3128
  • Fax:
Mailing address:
  • Phone: 559-754-3128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-IQROF
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: