Provider Demographics
NPI:1447582853
Name:GRAVES, IZETTA NICHOLE
Entity Type:Individual
Prefix:
First Name:IZETTA
Middle Name:NICHOLE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110-2656
Mailing Address - Country:US
Mailing Address - Phone:479-495-5177
Mailing Address - Fax:
Practice Address - Street 1:100 S CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110-2656
Practice Address - Country:US
Practice Address - Phone:479-495-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker