Provider Demographics
NPI:1164769030
Name:GRAHAM, LA RISA (APRN)
Entity Type:Individual
Prefix:
First Name:LA RISA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6143 SPRINGFIELD BLVD UNIT 640221
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11364-3480
Mailing Address - Country:US
Mailing Address - Phone:347-753-8833
Mailing Address - Fax:
Practice Address - Street 1:2 UNIVERISTY PLZ STE 100
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:347-753-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-11
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY794434163W00000X
NJ26NJ14844200363LP0808X
NY404814363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE