Healthcare Provider Details

I. General information

NPI: 1760282008
Provider Name (Legal Business Name): RAVEN VANTRYCE FITZPATRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PEACHTREE LN
FAIRVIEW HEIGHTS IL
62208-3801
US

IV. Provider business mailing address

5 PEACHTREE LN
FAIRVIEW HEIGHTS IL
62208-3801
US

V. Phone/Fax

Practice location:
  • Phone: 618-803-0372
  • Fax:
Mailing address:
  • Phone: 618-803-0372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: