Healthcare Provider Details

I. General information

NPI: 1073296257
Provider Name (Legal Business Name): RAVEN ORGERON MOORE MSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 01/27/2024
Certification Date: 01/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 RIDGE WAY DR
MANDEVILLE LA
70471-7461
US

IV. Provider business mailing address

1333 RIDGE WAY DR
MANDEVILLE LA
70471-7461
US

V. Phone/Fax

Practice location:
  • Phone: 225-328-1665
  • Fax:
Mailing address:
  • Phone: 225-328-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN110443
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number234256
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN110443
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: