Provider Demographics
NPI:1568059327
Name:GRAVES, AMANDA DAWN
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DAWN
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 1:325 HILLTOP AVE
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-2627
Mailing Address - Country:US
Mailing Address - Phone:304-813-1718
Mailing Address - Fax:
Practice Address - Street 1:325 HILLTOP AVE
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2627
Practice Address - Country:US
Practice Address - Phone:304-813-1718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0205488403747P1801X
WV0205-488403747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant