RAVEN CUSTALOW


Address: 17452 Richmond Rd, Callao, VA 22435
Phone: 8045296141

RAVEN CUSTALOW (NPI# 1669955019) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).

Provider Overview

Nation Provider ID (NPI) 1669955019
Entity Type Individual
Full Name RAVEN CUSTALOW
Credential AGPCNP-BC
Practice Address 17452 Richmond Rd
Callao
VA 22435
Mailing Address 359 Nottoway Ln
King William
VA 23086-3658
Practice Telephone 8045296141
Mailing Telephone 8049288477
Enumeration Date 2018-09-12
Last Update Date 2018-09-12
Gender Code F
Is Sole Proprietor N

Taxonomy

Primary Taxonomy Code Classification License Number License State Taxonomy Group
Y 363LP2300X Nurse Practitioner
Specialization: Primary Care
0024176579 VA Physician Assistants & Advanced Practice Nursing Providers

Office Location

Street Address 17452 RICHMOND RD
City CALLAO
State VA
Zip Code 22435

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1518083930 Beverly J Thomas Pharmacist 17422 Richmond Rd, Callao, VA 22435 2007-03-21
1982669081 Michael P. Chatterson Family Medicine 17452 Richmond Road, Callao, VA 22435 2006-04-20
1053834812 Walgreen Co Durable Medical Equipment & Medical Supplies 17422 Richmond Rd, Po Box 1059, Callao, VA 22435 2017-07-24
1962941278 Kingdomnaires Personal Transport Services, LLC Non-emergency Medical Transport (VAN) 1836 Hampton Hall Rd, Callao, VA 22435 2017-02-20
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Taxonomy Information

Taxonomy Code 363LP2300X
Grouping Physician Assistants & Advanced Practice Nursing Providers
Classification Nurse Practitioner
Specialization Primary Care

Taxonomy Definition

Definition to come...

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NPI Name Taxonomy Address Enumeration
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1689287583 Teela J Walker Nurse Practitioner 250 Craftsman Cir, Suffolk, VA 23434-1530 2020-08-28
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1346864725 Karen Guidry Nurse Practitioner 2102 Broad Branch Cir, Richmond, VA 23238-6459 2020-06-02
1588285662 Lindley Walker Abernathy Nurse Practitioner 25506 Courthouse Rd, Stony Creek, VA 23882-2042 2020-04-30
1952935777 Janice Oh Nurse Practitioner 7700 Little River Tpke Ste 102, Annandale, VA 22003-2400 2020-03-02
1003449448 Yasmine M Kletter Nurse Practitioner 15213 Addison Ln, Woodbridge, VA 22193-6223 2020-02-13
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Competitor

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City CALLAO
Zip Code 22435

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Dataset Information

Data Provider Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES)
Jurisdiction Medicare & Medicaid

This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.

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