Provider Demographics
NPI:1730719782
Name:GRAVESANDE, TRICIA S (NP)
Entity type:Individual
Prefix:MISS
First Name:TRICIA
Middle Name:S
Last Name:GRAVESANDE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-4001
Mailing Address - Country:US
Mailing Address - Phone:186-224-0940
Mailing Address - Fax:
Practice Address - Street 1:133 ELM ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-4001
Practice Address - Country:US
Practice Address - Phone:862-224-0940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00959600363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology