Provider Demographics
NPI:1972699452
Name:RAVENSCRAFT-EVANS, MOLLY KATHERINE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:KATHERINE
Last Name:RAVENSCRAFT-EVANS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:K
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-223-9945
Practice Address - Street 1:3301 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3713
Practice Address - Country:US
Practice Address - Phone:217-222-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0041244831367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL385190Medicare ID - Type Unspecified
IL041244831Medicaid