Provider Demographics
NPI:1154124832
Name:BARLESTON, RAVEN J'NAE
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:J'NAE
Last Name:BARLESTON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1449 N ASHLAND AVE APT 1R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2924 W MEDILL AVE APT 509
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-0688
Practice Address - Country:US
Practice Address - Phone:859-536-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.011805133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered