Provider Demographics
NPI:1568041168
Name:MOORE, RAVEN TPRING (AGNP-C)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:TPRING
Last Name:MOORE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2878 FIVE FORKS TRICKUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5896
Mailing Address - Country:US
Mailing Address - Phone:678-344-8700
Mailing Address - Fax:
Practice Address - Street 1:6175 NEWTON DR NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2690
Practice Address - Country:US
Practice Address - Phone:678-342-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN277339163WS0200X, 363LA2200X, 363LG0600X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WS0200XNursing Service ProvidersRegistered NurseSchool
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care