Provider Demographics
NPI:1609124635
Name:GRAHAM, TINA RENEE (FNP)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:RENEE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:RENEE
Other - Last Name:HENSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:BOX 70403
Mailing Address - Street 2:807 UNIVERSITY PKWY
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1703
Mailing Address - Country:US
Mailing Address - Phone:423-439-4071
Mailing Address - Fax:423-439-4060
Practice Address - Street 1:2151 CENTURY LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4469
Practice Address - Country:US
Practice Address - Phone:423-926-2500
Practice Address - Fax:423-926-5999
Is Sole Proprietor?:No
Enumeration Date:2012-08-23
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16914363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNAPN16914OtherSTATE LICENSE
TNRN154656OtherSTATE LICENSE