MEDICARE: YANET RAVELO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	71877	CT
2	207R00000X	Internal Medicine Physician	71877	CT

General Provider Information

NPI Number	:	1285139279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YANET RAVELO

Provider Business Mailing Address
First Line	:	75 BUCKINGHAM DR
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-2734
Country	:	US
Telephone Number	:	305-216-0746
Fax Number	:

Provider Business Practice Location Address
First Line	:	1216 FARMINGTON AVE STE 202
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06107-2673
Country	:	US
Telephone Number	:	860-236-0331
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	10/26/2022

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Directions to “ YANET RAVELO ” Practice Location

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