Healthcare Provider Details

I. General information

NPI: 1154971521
Provider Name (Legal Business Name): TIFFANY L GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7710 W INTERSTATE 10
SAN ANTONIO TX
78230-4711
US

IV. Provider business mailing address

7710 W INTERSTATE 10
SAN ANTONIO TX
78230-4711
US

V. Phone/Fax

Practice location:
  • Phone: 210-377-3355
  • Fax:
Mailing address:
  • Phone: 210-377-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC2100X
TaxonomyContinence Care Registered Nurse
License Number889357
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number889357
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: