Healthcare Provider Details

I. General information

NPI: 1316734791
Provider Name (Legal Business Name): OTHELL RAVEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 W BROAD AVE
ALBANY GA
31707-4343
US

IV. Provider business mailing address

1319 W BROAD AVE
ALBANY GA
31707-4343
US

V. Phone/Fax

Practice location:
  • Phone: 229-496-9147
  • Fax: 229-496-9258
Mailing address:
  • Phone: 229-496-9147
  • Fax: 229-496-9258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: