Provider Demographics
NPI:1568281244
Name:GRAVES, KIM (PTA)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:GRAVES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:GRAVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:176E W UNIVERSITY PKWY # E
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1616
Mailing Address - Country:US
Mailing Address - Phone:731-300-4950
Mailing Address - Fax:731-300-4951
Practice Address - Street 1:176E W UNIVERSITY PKWY # E
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1616
Practice Address - Country:US
Practice Address - Phone:731-300-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3497208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation