Healthcare Provider Details

I. General information

NPI: 1538701321
Provider Name (Legal Business Name): RAVEN CORNISH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RAVEN BARTLETT

II. Dates (important events)

Enumeration Date: 10/13/2019
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4922 WHITTIER BLVD
LOS ANGELES CA
90022-3115
US

IV. Provider business mailing address

626 TOPSAIL DR
VILLA RICA GA
30180-2319
US

V. Phone/Fax

Practice location:
  • Phone: 323-201-9343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAPRN-NP711759
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95011126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: