Basic Information
| Provider Information | |||||||||
| NPI: | 1790985182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARGRAVE | ||||||||
| FirstName: | GEORGIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLACKBURN | ||||||||
| OtherFirstName: | GEORGIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4 COMMERCE LANE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153939269 | ||||||||
| FaxNumber: | 3153933541 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 COMMERCE LANE | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152568191 | ||||||||
| FaxNumber: | 3153861410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2007 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F332447 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 03747862 | 05 | NY | MEDICAID |