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General NPI Number Information
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NPI Number | 1851910277
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Entity Type | Individual
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Provider Name | RAVEN CLAY
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Gender | Female
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Dates
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Enumeration Date | 04/15/2020
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Last Update Date | 04/15/2020
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Provider Practice Location Address
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Address Line | 5471 DR MARTIN LUTHER KING DR
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City | SAINT LOUIS
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State | MO
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Zip | 63112-4265
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Country | US
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Telephone | 314-633-6363
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Fax |
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Provider Business Mailing Address
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Address Line | 11 JOYCE ELLEN LN
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City | FERGUSON
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State | MO
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Zip | 63135-2140
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Country | US
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Telephone | 614-423-5243
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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 | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number | 113537A
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License Number State | MO
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