Provider Demographics
NPI:1497190417
Name:SMITH- BENTLEY, RAVEN (LPN)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:SMITH- BENTLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8295 MANTOVA DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041
Mailing Address - Country:US
Mailing Address - Phone:315-254-5230
Mailing Address - Fax:
Practice Address - Street 1:8295 MANTOVA DR
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-9168
Practice Address - Country:US
Practice Address - Phone:315-254-5230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314068164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse