Healthcare Provider Details

I. General information

NPI: 1881977684
Provider Name (Legal Business Name): MARK ALLEN GRAVES FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7723 CLEARVIEW CHURCH LN
LYLES TN
37098-1674
US

IV. Provider business mailing address

7723 CLEARVIEW CHURCH LN
LYLES TN
37098-1674
US

V. Phone/Fax

Practice location:
  • Phone: 931-670-5520
  • Fax: 931-670-5312
Mailing address:
  • Phone: 931-670-5520
  • Fax: 931-670-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16146
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: