Healthcare Provider Details

I. General information

NPI: 1679030001
Provider Name (Legal Business Name): MISS RAVEN SIMONE HAWKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 PEMBROKE LAKE CIR STE 202
VIRGINIA BEACH VA
23455-6436
US

IV. Provider business mailing address

4605 PEMBROKE LAKE CIR STE 202
VIRGINIA BEACH VA
23455-6436
US

V. Phone/Fax

Practice location:
  • Phone: 757-405-4681
  • Fax:
Mailing address:
  • Phone: 757-405-4681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHCO-0006332
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: