Healthcare Provider Details

I. General information

NPI: 1720736440
Provider Name (Legal Business Name): ARAEOFPHRESHAIR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/11/2022
Certification Date: 03/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 LINCOLN AVE # 1887
SAN JOSE CA
95125-3043
US

IV. Provider business mailing address

1165 LINCOLN AVE # 1887
SAN JOSE CA
95125-3043
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 TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RAVEN AMELIA CROSS
Title or Position: CEO
Credential: PMHNP
Phone: 408-372-8580