Provider Demographics
NPI:1720595044
Name:GRAVES, GLENN PHILIP (RN)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:PHILIP
Last Name:GRAVES
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-2849
Mailing Address - Country:US
Mailing Address - Phone:607-737-4927
Mailing Address - Fax:607-737-9080
Practice Address - Street 1:100 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2849
Practice Address - Country:US
Practice Address - Phone:607-737-4927
Practice Address - Fax:607-737-9080
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY652456-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse