Provider Demographics
NPI:1598327330
Name:GRAHAM, ANGELA FERGUSON (FNP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:FERGUSON
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 HILLCREST ESTATES LOOP
Mailing Address - Street 2:
Mailing Address - City:PETERSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:24963-1118
Mailing Address - Country:US
Mailing Address - Phone:304-557-9822
Mailing Address - Fax:
Practice Address - Street 1:159 HARTLEY WAY
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-2471
Practice Address - Country:US
Practice Address - Phone:540-853-0201
Practice Address - Fax:540-853-0931
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177989363L00000X
VA0001195632163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024177989OtherAPRN NURSE PRACTITIONER
VA0001195632OtherVA BOARD OF NURSING