Healthcare Provider Details

I. General information

NPI: 1740797182
Provider Name (Legal Business Name): RAVEN JEANEENE PIONTEK FNP-C, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 NW ARLINGTON AVE
LAWTON OK
73507-6537
US

IV. Provider business mailing address

619 E SOUTH BOUNDARY ST
WALTERS OK
73572-2839
US

V. Phone/Fax

Practice location:
  • Phone: 580-248-2288
  • Fax: 580-248-5757
Mailing address:
  • Phone: 580-919-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-133766
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number106583
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: