Provider Demographics
NPI:1679783666
Name:GRAVES, BRENDA KAY (RN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:GRAVES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6324 S COUNTY ROAD 3
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-9451
Mailing Address - Country:US
Mailing Address - Phone:970-686-5194
Mailing Address - Fax:
Practice Address - Street 1:1525 BLUE SPRUCE DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-2004
Practice Address - Country:US
Practice Address - Phone:970-498-6731
Practice Address - Fax:970-498-6772
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO52782163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07527823Medicaid