Provider Demographics
NPI:1578639548
Name:GRAHAM, MICHELLE L (CFNP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-831-2229
Mailing Address - Fax:228-539-8313
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:STE 300
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-831-2229
Practice Address - Fax:228-831-9991
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSR769918363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03983262Medicaid
MS$$$$$$$$$AOtherBCBS OF MS
MSQ32142Medicare UPIN