MEDICARE: MS. VANESSA CAROLINE GRAUDIEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist

General Provider Information

NPI Number	:	1861119968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VANESSA CAROLINE GRAUDIEL

Provider Business Mailing Address
First Line	:	6173 EHLERS PL APT 1
Second Line	:
City	:	FORT RILEY
State	:	KS
Zip	:	66442-2440
Country	:	US
Telephone Number	:	407-552-9078
Fax Number	:

Provider Business Practice Location Address
First Line	:	7670 PARKER ST
Second Line	:
City	:	FORT RILEY
State	:	KS
Zip	:	66442-4247
Country	:	US
Telephone Number	:	785-239-1202
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2022
Last Update Date	:	10/20/2022

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