Provider Demographics
NPI:1558577247
Name:GRAHAM, PAUL GERARD (RN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:GERARD
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11134 PRAIRIE WIND PL
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-6504
Mailing Address - Country:US
Mailing Address - Phone:815-623-2536
Mailing Address - Fax:
Practice Address - Street 1:11134 PRAIRIE WIND PL
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-6504
Practice Address - Country:US
Practice Address - Phone:815-623-2536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management