Provider Demographics
NPI:1407350663
Name:GRAVESANDY VASSALL, MOREMI ABENI (MD)
Entity type:Individual
Prefix:
First Name:MOREMI
Middle Name:ABENI
Last Name:GRAVESANDY VASSALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 64TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2267
Mailing Address - Country:US
Mailing Address - Phone:925-282-1778
Mailing Address - Fax:415-296-5299
Practice Address - Street 1:1480 64TH ST STE 150
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2267
Practice Address - Country:US
Practice Address - Phone:925-282-1778
Practice Address - Fax:415-296-5299
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3219802084P0800X
390200000X
CAA1771632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program