Healthcare Provider Details

I. General information

NPI: 1083835078
Provider Name (Legal Business Name): SALLY RAVANOS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7093
  • Fax: 919-784-7395
Mailing address:
  • Phone: 919-784-7093
  • Fax: 919-784-7395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-00012
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2009-00012
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: