Provider Demographics
NPI:1710511654
Name:GRAHAM, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 CITY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-1610
Mailing Address - Country:US
Mailing Address - Phone:215-871-6772
Mailing Address - Fax:
Practice Address - Street 1:212 W ROUTE 38 STE 400
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-3259
Practice Address - Country:US
Practice Address - Phone:856-235-0264
Practice Address - Fax:856-272-9416
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-01
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00594000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant