Provider Demographics
NPI:1407884356
Name:GRAHAM, ANGELA (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:ATKINSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CFNP
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-4222
Practice Address - Country:US
Practice Address - Phone:601-267-1470
Practice Address - Fax:601-267-1469
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123601Medicaid
MS0123601Medicaid
R855944Medicare UPIN