Healthcare Provider Details

I. General information

NPI: 1679805568
Provider Name (Legal Business Name): CARRIE RAGAN GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE RAGAN GARRETT

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 W JAMES LEE BLVD
CRESTVIEW FL
32536-2638
US

IV. Provider business mailing address

424 W JAMES LEE BLVD
CRESTVIEW FL
32536-2638
US

V. Phone/Fax

Practice location:
  • Phone: 850-689-2260
  • Fax: 850-398-6211
Mailing address:
  • Phone: 850-689-2260
  • Fax: 850-398-6211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberFS866660
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberEO1048
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: