Provider Demographics
NPI:1619404928
Name:GRAHAM, JENINE MARIE (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:JENINE
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11187 WOODS EDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BECKER
Mailing Address - State:MN
Mailing Address - Zip Code:55308-4553
Mailing Address - Country:US
Mailing Address - Phone:763-370-3515
Mailing Address - Fax:
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-240-2830
Is Sole Proprietor?:No
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5005363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner