Provider Demographics
NPI:1578573440
Name:GRAHAM, TYNNETTA (CRNP)
Entity Type:Individual
Prefix:
First Name:TYNNETTA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TYNNETTA
Other - Middle Name:
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 64888
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4888
Mailing Address - Country:US
Mailing Address - Phone:301-631-8101
Mailing Address - Fax:301-631-1002
Practice Address - Street 1:1000 CATHEDRAL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5418
Practice Address - Country:US
Practice Address - Phone:410-396-1295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR153464363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406596000Medicaid
MDT105Medicare PIN
MD406596000Medicaid
MD320LT105Medicare PIN