Healthcare Provider Details

I. General information

NPI: 1790922797
Provider Name (Legal Business Name): NICOLE ZANDER RAVEN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE BUSH RAVEN M.A.

II. Dates (important events)

Enumeration Date: 01/13/2009
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 SAND HILL RD STE 302
FLEMINGTON NJ
08822
US

IV. Provider business mailing address

1843 S BROAD ST
PHILADELPHIA PA
19148-2115
US

V. Phone/Fax

Practice location:
  • Phone: 908-788-9131
  • Fax: 908-788-0945
Mailing address:
  • Phone: 215-629-1353
  • Fax: 215-629-1395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number41YA00096400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: