Healthcare Provider Details

I. General information

NPI: 1639014210
Provider Name (Legal Business Name): RAVEEN WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 06/14/2026
Certification Date: 06/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WOODGATE DR
BRANDON MS
39042-2214
US

IV. Provider business mailing address

36 WOODGATE DR
BRANDON MS
39042-2214
US

V. Phone/Fax

Practice location:
  • Phone: 601-218-5269
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number916469
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: