1407884356 NPI number — MRS. ANGELA GRAHAM CFNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407884356 NPI number — MRS. ANGELA GRAHAM CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
ANGELA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAHAM
Provider Other First Name:
ANGELA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CFNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1407884356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
965 RIDGE LAKE BLVD STE 315
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38120-9401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17509 HIGHWAY 21 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEBASTOPOL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39359-0082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-267-1320
Provider Business Practice Location Address Fax Number:
601-267-5422
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R855944 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0123601 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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