Basic Information
| Provider Information | |||||||||
| NPI: | 1932262995 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | LINDA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1326 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756711326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9039273782 | ||||||||
| FaxNumber: | 9039271764 | ||||||||
| Practice Location | |||||||||
| Address1: | 4077 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718541509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703309200 | ||||||||
| FaxNumber: | 8703309439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 562258 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | A02971 ANP | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | A002971 | 01 | AR | NP LICENSE | OTHER |