Provider Demographics
NPI:1912704461
Name:GRAVATT, HAYDEN MARK
Entity type:Individual
Prefix:
First Name:HAYDEN
Middle Name:MARK
Last Name:GRAVATT
Suffix:
Gender:
Credentials:
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 37
Mailing Address - Street 2:
Mailing Address - City:JOHNSON
Mailing Address - State:NE
Mailing Address - Zip Code:68378-0037
Mailing Address - Country:US
Mailing Address - Phone:402-740-9829
Mailing Address - Fax:
Practice Address - Street 1:310 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:JOHNSON
Practice Address - State:NE
Practice Address - Zip Code:68378-8304
Practice Address - Country:US
Practice Address - Phone:402-740-9829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372500000X, 372600000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty