Provider Demographics
NPI:1043869738
Name:GRAVES, SHELLIE DEAN (NP)
Entity Type:Individual
Prefix:
First Name:SHELLIE
Middle Name:DEAN
Last Name:GRAVES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 PACIFIC COAST HWY
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-1313
Mailing Address - Country:US
Mailing Address - Phone:949-531-0963
Mailing Address - Fax:
Practice Address - Street 1:5000 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92674
Practice Address - Country:US
Practice Address - Phone:949-531-0963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95011932363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care