Provider Demographics
NPI:1548153505
Name:MOORE, RAVEN VICTORIA (MOT/S)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:VICTORIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:MOT/S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 MADISON AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3461
Mailing Address - Country:US
Mailing Address - Phone:901-448-8393
Mailing Address - Fax:
Practice Address - Street 1:3964 GOODMAN RD E STE 105
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-8711
Practice Address - Country:US
Practice Address - Phone:662-932-4652
Practice Address - Fax:662-932-4626
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program