Provider Demographics
NPI:1225345549
Name:GRAHAM, BETHANY ANNE (CNP)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANNE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 RALSTON AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-5311
Mailing Address - Country:US
Mailing Address - Phone:419-782-8332
Mailing Address - Fax:419-782-6855
Practice Address - Street 1:1250 RALSTON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-5311
Practice Address - Country:US
Practice Address - Phone:419-782-8332
Practice Address - Fax:419-782-6855
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP11740363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGRNP37611OtherMEDICARE
OH3093558Medicaid