Provider Demographics
NPI:1275549172
Name:GRAHAM, GLORIA L (NP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:L
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 HWY 77 S
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-2367
Mailing Address - Country:US
Mailing Address - Phone:870-739-5311
Mailing Address - Fax:870-739-5542
Practice Address - Street 1:2921 HWY 77 S
Practice Address - Street 2:SUITE 20
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-2367
Practice Address - Country:US
Practice Address - Phone:870-739-5311
Practice Address - Fax:870-739-5542
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01560363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR159872758Medicaid
Q45613Medicare UPIN