Provider Demographics
NPI:1730484171
Name:GRAHAM, ALLYSSA BAUCOM (APRN)
Entity Type:Individual
Prefix:MS
First Name:ALLYSSA
Middle Name:BAUCOM
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 YORK ST APT 21C
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5640
Mailing Address - Country:US
Mailing Address - Phone:203-393-5325
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-16
Last Update Date:2011-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004548363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care