Provider Demographics
NPI:1255941316
Name:GRAVELY, ITAI
Entity type:Individual
Prefix:
First Name:ITAI
Middle Name:
Last Name:GRAVELY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1863 SUGAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-1344
Mailing Address - Country:US
Mailing Address - Phone:304-807-4803
Mailing Address - Fax:
Practice Address - Street 1:1863 SUGAR CREEK DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-1344
Practice Address - Country:US
Practice Address - Phone:304-807-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant