Provider Demographics
NPI:1902134349
Name:GRAVES, KIMBERLY MICHELE
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:MICHELE
Last Name:GRAVES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 STATE HIGHWAY 206
Mailing Address - Street 2:
Mailing Address - City:GREENE
Mailing Address - State:NY
Mailing Address - Zip Code:13778-2384
Mailing Address - Country:US
Mailing Address - Phone:607-656-4399
Mailing Address - Fax:
Practice Address - Street 1:2529 STATE HIGHWAY 206
Practice Address - Street 2:
Practice Address - City:GREENE
Practice Address - State:NY
Practice Address - Zip Code:13778-2384
Practice Address - Country:US
Practice Address - Phone:607-656-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008341-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician