Healthcare Provider Details

I. General information

NPI: 1134562564
Provider Name (Legal Business Name): VIRGINIA GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 GROVE ST
AUBURNDALE MA
02466-2272
US

IV. Provider business mailing address

2 SILVER CT
BEVERLY MA
01915-5021
US

V. Phone/Fax

Practice location:
  • Phone: 617-454-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN108113
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: