Healthcare Provider Details

I. General information

NPI: 1215302195
Provider Name (Legal Business Name): MRS. WHITNEY GRAVELLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WHITNEY ANN PIRTLE

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5148A MURFREESBORO RD
LA VERGNE TN
37086-2712
US

IV. Provider business mailing address

5148A MURFREESBORO RD
LA VERGNE TN
37086-2712
US

V. Phone/Fax

Practice location:
  • Phone: 615-213-2273
  • Fax: 615-213-2271
Mailing address:
  • Phone: 615-213-2273
  • Fax: 615-213-2271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2911
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: