Healthcare Provider Details

I. General information

NPI: 1679095772
Provider Name (Legal Business Name): RAVEENA NALLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 GOODMAN RD STE 1
OLIVE BRANCH MS
38654-7902
US

IV. Provider business mailing address

1211 UNION AVE STE 330
MEMPHIS TN
38104-6655
US

V. Phone/Fax

Practice location:
  • Phone: 662-874-6507
  • Fax: 662-932-8197
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number29883
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: