Provider Demographics
NPI:1366842783
Name:GRAVES, KELLI MICHELE (STATE TESTED)
Entity Type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:MICHELE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:STATE TESTED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13512 FOURTH
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112
Mailing Address - Country:US
Mailing Address - Phone:216-882-1937
Mailing Address - Fax:
Practice Address - Street 1:13512 4TH AVE
Practice Address - Street 2:
Practice Address - City:EAST CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-3116
Practice Address - Country:US
Practice Address - Phone:216-882-1937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4014782601133747P1801X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide