Provider Demographics
NPI:1366932857
Name:RAVENHALL, GEORGETTE (RDN, CDN)
Entity type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:
Last Name:RAVENHALL
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:MRS
Other - First Name:GEORGETTE
Other - Middle Name:
Other - Last Name:RAVENHALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:625 BELLE TERRE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2318
Mailing Address - Country:US
Mailing Address - Phone:631-686-2513
Mailing Address - Fax:
Practice Address - Street 1:17 WILL BUTLER LANE
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:ME
Practice Address - Zip Code:04551-0455
Practice Address - Country:US
Practice Address - Phone:631-219-8929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1773133V00000X
NY86063967133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered