Healthcare Provider Details

I. General information

NPI: 1669665618
Provider Name (Legal Business Name): LUANN ELY GRAVES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2007
Last Update Date: 08/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N MAIN ST BUILDING 1, ROOM 162
WHITE RIVER JUNCTION VT
05009-0001
US

IV. Provider business mailing address

74 BUTTERNUT RD
NORWICH VT
05055-9790
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-9363
  • Fax: 802-296-6476
Mailing address:
  • Phone: 802-649-3957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: