Healthcare Provider Details

I. General information

NPI: 1306781596
Provider Name (Legal Business Name): KELNEIRICKA GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5373 ALLATOONA GTWY APT 415
ACWORTH GA
30102-1866
US

IV. Provider business mailing address

5373 ALLATOONA GTWY APT 415
ACWORTH GA
30102-1866
US

V. Phone/Fax

Practice location:
  • Phone: 404-399-1666
  • Fax:
Mailing address:
  • Phone: 404-399-1666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberCN0030007649
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: