Provider Demographics
NPI:1932154176
Name:HARGRAVES, ANDREA M (CNM)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:M
Last Name:HARGRAVES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1479
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1479
Mailing Address - Country:US
Mailing Address - Phone:229-226-8800
Mailing Address - Fax:229-226-8232
Practice Address - Street 1:916 S BROAD ST
Practice Address - Street 2:UNIT B-2
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6113
Practice Address - Country:US
Practice Address - Phone:229-226-8800
Practice Address - Fax:229-226-8232
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN148927367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00867831CMedicaid
GA000867831FMedicaid
GA00867831AMedicaid
GA000867831FMedicaid
GA00867831CMedicaid