Provider Demographics
NPI:1699741595
Name:GRAVES, SALLY ANN (CRNA)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:GRAVES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:ANN
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3549
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-0549
Mailing Address - Country:US
Mailing Address - Phone:423-698-3309
Mailing Address - Fax:423-624-6355
Practice Address - Street 1:2341 MCCALLIE AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3239
Practice Address - Country:US
Practice Address - Phone:423-698-3309
Practice Address - Fax:423-624-6355
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN11183367500000X
TNRN60849367500000X
GARN84232367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3622714Medicaid
TN3053299OtherBCBS
TN3053299OtherBCBS