Provider Demographics
NPI:1124607908
Name:LEE, RAVEN KIARA (LPN)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:KIARA
Last Name:LEE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:KIARA
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:6681 BOYLSTON DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38141-0770
Mailing Address - Country:US
Mailing Address - Phone:901-759-8482
Mailing Address - Fax:
Practice Address - Street 1:340 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1610
Practice Address - Country:US
Practice Address - Phone:662-579-3955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS329980164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse