Provider Demographics
NPI:1215203138
Name:GRAHAM, STACEY A (ACNP-BC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 S GREENE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1544
Mailing Address - Country:US
Mailing Address - Phone:410-328-3179
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-3179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-25
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR175041363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care