Provider Demographics
NPI:1376764225
Name:GRAHAM, KIM (NP-C)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:GRENNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 OLD JACOBS RD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01833-1009
Mailing Address - Country:US
Mailing Address - Phone:978-352-7540
Mailing Address - Fax:
Practice Address - Street 1:298 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:MA
Practice Address - Zip Code:01930-4832
Practice Address - Country:US
Practice Address - Phone:978-283-7580
Practice Address - Fax:978-283-0456
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA168831363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner