Provider Demographics
NPI:1003778242
Name:RAVANBAKHSH, SEYEDEH-SOGOL
Entity type:Individual
Prefix:
First Name:SEYEDEH-SOGOL
Middle Name:
Last Name:RAVANBAKHSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOGOL
Other - Middle Name:
Other - Last Name:RAVANBAKHSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:35 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4417
Mailing Address - Country:US
Mailing Address - Phone:802-651-1018
Mailing Address - Fax:
Practice Address - Street 1:35 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4417
Practice Address - Country:US
Practice Address - Phone:802-651-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-25
Last Update Date:2025-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH1001432183500000X
VT033.0135909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist