Provider Demographics
NPI:1043410210
Name:SMITH-GRAVELLE, DAWN MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MARIE
Last Name:SMITH-GRAVELLE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16250 EVANS RD
Mailing Address - Street 2:PO BOX 675
Mailing Address - City:DEXTER
Mailing Address - State:NY
Mailing Address - Zip Code:13634-3048
Mailing Address - Country:US
Mailing Address - Phone:315-639-4895
Mailing Address - Fax:
Practice Address - Street 1:16250 EVANS RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:NY
Practice Address - Zip Code:13634-3048
Practice Address - Country:US
Practice Address - Phone:315-639-4895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160181-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02660891Medicaid