Basic Information
| Provider Information | |||||||||
| NPI: | 1134701642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOATMAN | ||||||||
| FirstName: | RAVEN | ||||||||
| MiddleName: | CELESTE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23845 HIGHWAY 8 E | ||||||||
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| City: | GRENADA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389019148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626148291 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1966 F S HILL DR | ||||||||
| Address2: | |||||||||
| City: | GRENADA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389015047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622262442 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2021 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA6380 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.