Provider Demographics
NPI:1871285692
Name:PERRY, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:PERRY
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 1:4101 NORTHBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-3921
Mailing Address - Country:US
Mailing Address - Phone:901-270-1286
Mailing Address - Fax:
Practice Address - Street 1:4101 NORTHBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-3921
Practice Address - Country:US
Practice Address - Phone:901-270-1286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No174400000XOther Service ProvidersSpecialist