Provider Demographics
NPI:1376904797
Name:GRAVES, CARLA (RDN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 METRO CT
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-1765
Mailing Address - Country:US
Mailing Address - Phone:484-889-1611
Mailing Address - Fax:
Practice Address - Street 1:671 METRO CT
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-1765
Practice Address - Country:US
Practice Address - Phone:484-889-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-12
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86028570133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered