Basic Information
| Provider Information | |||||||||
| NPI: | 1871222562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | GWENDRA | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51434 OLD ROUTE 50 | ||||||||
| Address2: | |||||||||
| City: | LONDONDERRY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456478907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 51434 OLD ROUTE 50 | ||||||||
| Address2: | |||||||||
| City: | LONDONDERRY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456478907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407731141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2022 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA2000X | 280084 | OH | Y | Nursing Service Providers | Registered Nurse | Administrator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.