Healthcare Provider Details

I. General information

NPI: 1649812827
Provider Name (Legal Business Name): ROXANNE LEIGH GRAVLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2019
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 E MAIN ST
FRIES VA
24330
US

IV. Provider business mailing address

412 E MAIN ST
INDEPENDENCE VA
24348-3954
US

V. Phone/Fax

Practice location:
  • Phone: 276-744-7201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306604190
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: