Provider Demographics
NPI:1295886257
Name:GRAVES, SANDRA SUE
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:SUE
Last Name:GRAVES
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 1:981 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-9368
Mailing Address - Country:US
Mailing Address - Phone:740-385-2036
Mailing Address - Fax:
Practice Address - Street 1:15162 MOHLER RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138
Practice Address - Country:US
Practice Address - Phone:740-385-1323
Practice Address - Fax:740-385-2036
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2371526OtherWAIVER