Raven Custalow, AGPCNP-BC
Individual provider Active NPI Primary Care Nurse Practitioner · Aylett, VA
NPI 1669955019 · NPPES record last updated Nov 8, 2024
Key facts
- NPI
- 1669955019
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Primary Care Nurse Practitioner 363LP2300X
- License
- 0024176579 (VA)
- Practice address
- 7864 Richmond Tappahannock Hwy
Aylett, VA 23009-3056 - Phone
- (804) 769-2015
- NPI assigned
- Sep 12, 2018
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 3
Hospital & facility affiliations 2
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Georgetown University School of Medicine, 2018
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Upper Mattaponi Indian Tribe
Practice addresses (Care Compare)
7864 Richmond Tappahannock Hwy
Aylett, VA 23009-3056
Phone (804) 769-2015
Hospital & facility affiliations
- Vcu Health Tappahannock Hospital
- Bon Secours Memorial Regional Medical Center
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in TX
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20241104002126 | TX | Practitioner - Nurse Practitioner | 0840543013 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0024176579 | VA | MD | Primary Care Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Upper Mattaponi Indian Tribe | Current |
Accepting new patients | |
| Upper Mattaponi Indian Tribe | Current |
Accepting new patients |
Locations
7864 Richmond Tappahannock Hwy
Aylett, VA 23009
Phone (804) 746-1677
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Primary Care Nurse Practitioner | 363LP2300X | 0024176579 | VA | Yes |
Addresses
Primary practice location
7864 Richmond Tappahannock Hwy
Aylett, VA 23009-3056
Mailing address
3944 Upshaw Rd
Aylett, VA 23009-2912
Phone (804) 928-8477
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 3001529971 | Medicaid | VA |
Other providers in Aylett, VA
- Samone Boyd
- Latricia Broaddus
- Lily Alemi Cameron
- Central Virginia Health Services Inc
- Joanne Lynne Cunningham
- Jessica D'Aurora
- Faithhopelove, LLC
- Andrea Garrett
- Christina Barrett Hawkins
- Its All About Caring LLC
All providers in Aylett, VA · Primary Care Nurse Practitioner in Virginia
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 8, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.