Provider Demographics
NPI:1871928556
Name:GRAVENOR, SHIRLEY (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:
Last Name:GRAVENOR
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 1:2636 PARK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38139-6556
Mailing Address - Country:US
Mailing Address - Phone:901-737-7779
Mailing Address - Fax:
Practice Address - Street 1:2636 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139-6556
Practice Address - Country:US
Practice Address - Phone:901-737-7779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000034785207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine