Basic Information
| Provider Information | |||||||||
| NPI: | 1720741812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OMUEMU | ||||||||
| FirstName: | RAVEN | ||||||||
| MiddleName: | ADAIR | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | APRN, PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 153 MAGAZINE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011094016 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 153 MAGAZINE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011094016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137345376 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2021 | ||||||||
| LastUpdateDate: | 07/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | NA | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.