Healthcare Provider Details

I. General information

NPI: 1275664708
Provider Name (Legal Business Name): AMY MELISSA GRAVES OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11517 KANIS RD
LITTLE ROCK AR
72211-3724
US

IV. Provider business mailing address

8 WINONA DR
MAUMELLE AR
72113-6301
US

V. Phone/Fax

Practice location:
  • Phone: 501-993-7171
  • Fax: 501-223-8075
Mailing address:
  • Phone: 501-658-8871
  • Fax: 501-803-3641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberOTR1609
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: