Healthcare Provider Details

I. General information

NPI: 1760100283
Provider Name (Legal Business Name): NIESHA QIANA GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4812 MERRIFIELD PL
UPPER ARLINGTON OH
43220-5435
US

IV. Provider business mailing address

4812 MERRIFIELD PL
UPPER ARLINGTON OH
43220-5435
US

V. Phone/Fax

Practice location:
  • Phone: 313-433-0151
  • Fax:
Mailing address:
  • Phone: 313-433-0151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: