Provider Demographics
NPI:1467582197
Name:GRAHAM, TERESA KEM (CNP)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:KEM
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 1:225 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1539
Mailing Address - Country:US
Mailing Address - Phone:517-263-1800
Mailing Address - Fax:517-263-1866
Practice Address - Street 1:8765 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-9583
Practice Address - Country:US
Practice Address - Phone:734-847-3802
Practice Address - Fax:734-847-3418
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-09190363LF0000X
MI4704198775363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI54924OtherHEALTH PLAN OF MICHIGAN
231807Medicare Oscar/Certification
MI54924OtherHEALTH PLAN OF MICHIGAN
MI0E86031Medicare PIN