Basic Information
Provider Information | |||||||||
NPI: | 1336237833 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAVES | ||||||||
FirstName: | KAREN | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP, BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1701 WHITE ST | ||||||||
Address2: |   | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396482711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016842173 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1701 WHITE ST | ||||||||
Address2: |   | ||||||||
City: | MCCOMB | ||||||||
State: | MS | ||||||||
PostalCode: | 396482711 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016842173 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2006 | ||||||||
LastUpdateDate: | 07/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 23786.0844 | WY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0808X | 23786.0844 | WY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 363LP0808X | R853137 | MS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 314347 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER |