Healthcare Provider Details

I. General information

NPI: 1124949664
Provider Name (Legal Business Name): RAVEN HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 COMMERCIAL DR UNIT 2
PAHRUMP NV
89048-4704
US

IV. Provider business mailing address

1145 PARK DR
FAIRBANKS AK
99709-4714
US

V. Phone/Fax

Practice location:
  • Phone: 725-253-5127
  • Fax:
Mailing address:
  • Phone: 907-388-6308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANGEL AMBROSE
Title or Position: OWNER
Credential:
Phone: 907-388-6308