Provider Demographics
NPI:1639437379
Name:GRAVES, STACI ROBIN (PA)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:ROBIN
Last Name:GRAVES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:STACI
Other - Middle Name:ROBIN
Other - Last Name:SULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:715 E 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6148
Mailing Address - Country:US
Mailing Address - Phone:706-291-9898
Mailing Address - Fax:
Practice Address - Street 1:715 E 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6148
Practice Address - Country:US
Practice Address - Phone:706-291-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical