Provider Demographics
NPI:1467766261
Name:GRAVENS, COURTNEY BROOKE (MSN, RN)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:BROOKE
Last Name:GRAVENS
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5141 SHEPHERDS GLN
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-3388
Mailing Address - Country:US
Mailing Address - Phone:440-487-8508
Mailing Address - Fax:
Practice Address - Street 1:8655 MARKET STREET
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-255-6400
Practice Address - Fax:440-255-3637
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16149-NP363LF0000X
OHCOA.16149163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0106908Medicaid