Healthcare Provider Details

I. General information

NPI: 1952352098
Provider Name (Legal Business Name): RAVEN DEDRICK WENTWORTH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

847 SQUIRREL HOLLOW DR
LINDEN TN
37096-6479
US

IV. Provider business mailing address

847 SQUIRREL HOLLOW DR PO BOX 56
LINDEN TN
37096-6479
US

V. Phone/Fax

Practice location:
  • Phone: 931-589-2600
  • Fax:
Mailing address:
  • Phone: 931-589-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPN11711
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11711
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: