Healthcare Provider Details

I. General information

NPI: 1720741812
Provider Name (Legal Business Name): RAVEN ADAIR OMUEMU APRN, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2021
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 MAGAZINE ST
SPRINGFIELD MA
01109-4016
US

IV. Provider business mailing address

153 MAGAZINE ST
SPRINGFIELD MA
01109-4016
US

V. Phone/Fax

Practice location:
  • Phone: 413-734-5376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNA
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: