1720530629 NPI number — KELLY GRAHAM FNP

Table of content: KELLY GRAHAM FNP (NPI 1720530629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720530629 NPI number — KELLY GRAHAM FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEMARCO
Provider Other First Name:
KELLY
Provider Other Middle Name:
DAWN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720530629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23501-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-689-5104
Provider Business Mailing Address Fax Number:
757-689-2717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
213 RIVER WALK PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-6893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-983-1777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2016

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:  0024173581 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720530629 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1720530629 . This is a "MULTIPLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720530629 . This is a "CORVEL" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720530629 . This is a "HUMANA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720530629 . This is a "USA MANAGED CARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720530629 . This is a "VIRGINIA PREMIER HEALTH PLAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720530629 . This is a "TRICARE/CHAMPUS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720530629 . This is a "OPTIMA HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1720530629 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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