Provider Demographics
NPI:1386907566
Name:GUY, RAVEN (LPN)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:GUY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-2423
Mailing Address - Country:US
Mailing Address - Phone:631-398-8966
Mailing Address - Fax:
Practice Address - Street 1:530 MASTIC RD
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-1012
Practice Address - Country:US
Practice Address - Phone:631-433-0598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304095164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse