Provider Demographics
NPI:1427480169
Name:GRAVELL, JORDAN A (CRNA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:A
Last Name:GRAVELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-778-7608
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN165420163W00000X
TNAPN17947367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse