1649279399 NPI number — MS. STACEY K GRAVES MSN, CRNP

Table of content: MS. STACEY K GRAVES MSN, CRNP (NPI 1649279399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649279399 NPI number — MS. STACEY K GRAVES MSN, CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVES
Provider First Name:
STACEY
Provider Middle Name:
K
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSN, CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649279399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 PENNS WAY
Provider Second Line Business Mailing Address:
SUITE 412
Provider Business Mailing Address City Name:
NEW CASTLE
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-652-2455
Provider Business Mailing Address Fax Number:
302-322-6251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 MARROWS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19713-3701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-455-0900
Provider Business Practice Location Address Fax Number:
302-455-0902
Provider Enumeration Date:
07/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  LG-0000360 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1000041379 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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