MEDICARE: ARAEOFPHRESHAIR LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1720736440
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARAEOFPHRESHAIR LLC

Provider Business Mailing Address
First Line	:	1165 LINCOLN AVE # 1887
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-3043
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1165 LINCOLN AVE # 1887
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-3043
Country	:	US
Telephone Number	:	408-372-8580
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RAVEN AMELIA CROSS
Credential	:	PMHNP
Telephone Number	:	408-372-8580

Provider Enumeration Date	:	03/11/2022
Last Update Date	:	03/11/2022

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Directions to “ARAEOFPHRESHAIR LLC ” Practice Location

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