Provider Demographics
NPI:1760021539
Name:GRAHAM, DIANE (APRN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
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 1:44 FRANK ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-4645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1622 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-2776
Practice Address - Country:US
Practice Address - Phone:475-209-9130
Practice Address - Fax:203-298-4380
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-27
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT8667363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty