Basic Information
| Provider Information | |||||||||
| NPI: | 1942784145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYBORN | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | QUINN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICHOLS | ||||||||
| OtherFirstName: | CAITLIN | ||||||||
| OtherMiddleName: | QUINN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1215 LEE ST MAIL STOP | ||||||||
| Address2: | #800501 | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245321 | ||||||||
| FaxNumber: | 4349823816 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 LEE ST MAIL STOP | ||||||||
| Address2: | #800501 | ||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349245321 | ||||||||
| FaxNumber: | 4349823816 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2018 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116034460 | VA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.