Provider Demographics
NPI:1871222562
Name:GRAVES, GWENDRA G (RN)
Entity Type:Individual
Prefix:MS
First Name:GWENDRA
Middle Name:G
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 1:51434 OLD ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:OH
Mailing Address - Zip Code:45647-8907
Mailing Address - Country:US
Mailing Address - Phone:740-773-1141
Mailing Address - Fax:
Practice Address - Street 1:51434 OLD ROUTE 50
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:OH
Practice Address - Zip Code:45647-8907
Practice Address - Country:US
Practice Address - Phone:740-773-1141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH280084163WA2000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program