Provider Demographics
NPI:1598090458
Name:GRAVES, KIM ELAINE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:ELAINE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 932759
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0015
Mailing Address - Country:US
Mailing Address - Phone:937-293-8228
Mailing Address - Fax:937-293-8229
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-293-8228
Practice Address - Fax:937-293-8229
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA10992NP363L00000X, 363LA2100X
OHCOA11519NA367500000X
OHAPRN.CRNA.11519367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHNP36822Medicare PIN