Provider Demographics
NPI:1366973109
Name:GRAGG, SHIRLEY JEAN (LPN II,NREMT-B,CIC-C)
Entity type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:JEAN
Last Name:GRAGG
Suffix:
Gender:F
Credentials:LPN II,NREMT-B,CIC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 LA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-2619
Mailing Address - Country:US
Mailing Address - Phone:719-334-6584
Mailing Address - Fax:
Practice Address - Street 1:2118 CHATALET LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-4625
Practice Address - Country:US
Practice Address - Phone:719-564-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLEMT 511744146N00000X
COPN.0047668164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic