Provider Demographics
NPI:1316734791
Name:RAVEN, OTHELL
Entity type:Individual
Prefix:
First Name:OTHELL
Middle Name:
Last Name:RAVEN
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 1:1319 W BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-4343
Mailing Address - Country:US
Mailing Address - Phone:229-496-9147
Mailing Address - Fax:229-496-9258
Practice Address - Street 1:1319 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-4343
Practice Address - Country:US
Practice Address - Phone:229-496-9147
Practice Address - Fax:229-496-9258
Is Sole Proprietor?:No
Enumeration Date:2025-04-21
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide