Healthcare Provider Details

I. General information

NPI: 1285539221
Provider Name (Legal Business Name): RAVEN SAMANTHA PEGUERO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

45 SHONNARD AVE
FREEPORT NY
11520-2416
US

IV. Provider business mailing address

45 SHONNARD AVE
FREEPORT NY
11520-2416
US

V. Phone/Fax

Practice location:
  • Phone: 516-234-0980
  • Fax:
Mailing address:
  • Phone: 516-234-0980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: