Provider Demographics
NPI:1073566279
Name:CARLEY-GRAVES, SUE A (NP)
Entity Type:Individual
Prefix:MS
First Name:SUE
Middle Name:A
Last Name:CARLEY-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 1:19320 US ROUTE 11
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-5337
Mailing Address - Country:US
Mailing Address - Phone:315-786-0254
Mailing Address - Fax:315-786-0976
Practice Address - Street 1:19320 US ROUTE 11
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-5337
Practice Address - Country:US
Practice Address - Phone:315-786-0254
Practice Address - Fax:315-786-0976
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300711363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02147400Medicaid
NY02147400Medicaid
NYPO1641Medicare UPIN