Basic Information
| Provider Information | |||||||||
| NPI: | 1649279399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 PENNS WAY | ||||||||
| Address2: | SUITE 412 | ||||||||
| City: | NEW CASTLE | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026522455 | ||||||||
| FaxNumber: | 3023226251 | ||||||||
| Practice Location | |||||||||
| Address1: | 27 MARROWS RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197133701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3024550900 | ||||||||
| FaxNumber: | 3024550902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2005 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | LG-0000360 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1000041379 | 05 | DE | MEDICAID |