Healthcare Provider Details

I. General information

NPI: 1720903099
Provider Name (Legal Business Name): RAVEN WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 GAUSE BLVD
SLIDELL LA
70458-2948
US

IV. Provider business mailing address

30720 ROWLEY DR
LACOMBE LA
70445-2946
US

V. Phone/Fax

Practice location:
  • Phone: 601-917-1503
  • Fax:
Mailing address:
  • Phone: 601-917-1503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number203608
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: