Provider Demographics
NPI:1366257362
Name:GRAVATT, NICOLE MARIE (LPN)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:GRAVATT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:JOHNSON
Mailing Address - State:NE
Mailing Address - Zip Code:68378-0037
Mailing Address - Country:US
Mailing Address - Phone:402-250-6099
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 37
Practice Address - Street 2:
Practice Address - City:JOHNSON
Practice Address - State:NE
Practice Address - Zip Code:68378-0037
Practice Address - Country:US
Practice Address - Phone:402-250-6099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-08
Last Update Date:2025-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372500000X, 372600000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty