Provider Demographics
NPI:1639273170
Name:GRAHAM, KIMBERLY DANE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DANE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 HOSPICE CIR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6372
Mailing Address - Country:US
Mailing Address - Phone:919-828-0890
Mailing Address - Fax:
Practice Address - Street 1:250 HOSPICE CIR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6372
Practice Address - Country:US
Practice Address - Phone:919-828-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900289363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC500026240OtherRAILROAD-MEDICARE
NCP64950Medicare UPIN
NC2599499Medicare PIN