Healthcare Provider Details

I. General information

NPI: 1164256913
Provider Name (Legal Business Name): ETHAN DICKSON GRAVES RN, CCRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5959 PARK AVE
MEMPHIS TN
38119-5198
US

IV. Provider business mailing address

5094 SUMMER MIST CV
ARLINGTON TN
38002-4366
US

V. Phone/Fax

Practice location:
  • Phone: 901-765-1000
  • Fax:
Mailing address:
  • Phone: 731-414-3620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: