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General NPI Number Information
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NPI Number | 1124607908
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Entity Type | Individual
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Provider Name | RAVEN KIARA LEE LPN
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Gender | Female
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Dates
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Enumeration Date | 04/07/2021
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Last Update Date | 04/07/2021
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Provider Practice Location Address
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Address Line | 340 STATELINE RD W
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City | SOUTHAVEN
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State | MS
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Zip | 38671-1610
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Country | US
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Telephone | 662-579-3955
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Fax |
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Provider Business Mailing Address
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Address Line | 6681 BOYLSTON DR
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City | MEMPHIS
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State | TN
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Zip | 38141-0770
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Country | US
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Telephone | 901-759-8482
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 329980
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License Number State | MS
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