Provider Demographics
NPI:1003543042
Name:GRAVES, KENNEDY ALISE
Entity Type:Individual
Prefix:
First Name:KENNEDY
Middle Name:ALISE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9739 TROON CT
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45241-3349
Mailing Address - Country:US
Mailing Address - Phone:513-484-2822
Mailing Address - Fax:
Practice Address - Street 1:615 IRVING SCHOTTENSTEIN DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1069
Practice Address - Country:US
Practice Address - Phone:614-293-1634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program