Provider Demographics
NPI:1881849651
Name:GRAVEL, MARY K (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:GRAVEL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N STATE ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-1658
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:
Practice Address - Street 1:1421 N STATE ST
Practice Address - Street 2:SUITE 203
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1658
Practice Address - Country:US
Practice Address - Phone:601-355-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-20
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LATAP1958367500000X
MSR526401367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered