Healthcare Provider Details

I. General information

NPI: 1982242426
Provider Name (Legal Business Name): MICHELLE L GRAVES PNPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TELCOM DR
BANGOR ME
04401-3072
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-0147
  • Fax: 207-990-3365
Mailing address:
  • Phone: 207-404-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP201008
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: