Healthcare Provider Details

I. General information

NPI: 1114596624
Provider Name (Legal Business Name): RAVEN CROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 LINCOLN AVE STE 150
SAN JOSE CA
95125-3045
US

IV. Provider business mailing address

1165 LINCOLN AVE STE 150
SAN JOSE CA
95125-3045
US

V. Phone/Fax

Practice location:
  • Phone: 408-372-8580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number95142217
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0024183375
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019647
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: