Provider Demographics
NPI:1861278962
Name:GRAVES, SHANNON LEIGH
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:LEIGH
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 1:2620 MANOR STONE WAY
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-8899
Mailing Address - Country:US
Mailing Address - Phone:607-341-0159
Mailing Address - Fax:
Practice Address - Street 1:8304 CREEDMOOR RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-1697
Practice Address - Country:US
Practice Address - Phone:919-870-8409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCGRAV-W91JR363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health