1861949505 NPI number — MISS JUANITA CHARISE GRAVES LPN

Table of content: MISS JUANITA CHARISE GRAVES LPN (NPI 1861949505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861949505 NPI number — MISS JUANITA CHARISE GRAVES LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVES
Provider First Name:
JUANITA
Provider Middle Name:
CHARISE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LPN
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:
1861949505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
294 HASTINGS AVE
Provider Second Line Business Mailing Address:
LOWER
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14215-2988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-603-6448
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
294 HASTINGS AVE
Provider Second Line Business Practice Location Address:
LOWER
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14215-2988
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-603-6448
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2016

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: 164W00000X , with the licence number:  264876-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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