Provider Demographics
NPI:1003591900
Name:GRAVELINE, ASHLEY MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:GRAVELINE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MARIE
Other - Last Name:BRODEUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 MEDICAL CENTER DR STE 410
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1273
Mailing Address - Country:US
Mailing Address - Phone:413-748-7095
Mailing Address - Fax:
Practice Address - Street 1:300 STAFFORD ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-4110
Practice Address - Country:US
Practice Address - Phone:413-748-7095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2266468363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse