Provider Demographics
NPI:1043952500
Name:VEGA, RAVEN SYMONE
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:SYMONE
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-3205
Mailing Address - Country:US
Mailing Address - Phone:502-585-9911
Mailing Address - Fax:
Practice Address - Street 1:215 CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1451
Practice Address - Country:US
Practice Address - Phone:502-637-7678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-13
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer