Provider Demographics
NPI:1063253136
Name:MOORE, RAVEN
Entity type:Individual
Prefix:MS
First Name:RAVEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 CHIEF CT
Mailing Address - Street 2:
Mailing Address - City:ROCKMART
Mailing Address - State:GA
Mailing Address - Zip Code:30153-8020
Mailing Address - Country:US
Mailing Address - Phone:678-994-6085
Mailing Address - Fax:
Practice Address - Street 1:154 CHIEF CT
Practice Address - Street 2:
Practice Address - City:ROCKMART
Practice Address - State:GA
Practice Address - Zip Code:30153-8020
Practice Address - Country:US
Practice Address - Phone:678-994-6085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAJ6G4Z3L9246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy