Provider Demographics
NPI:1982660395
Name:GRAHAM, KIMBERLY (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5219 CITY BANK PKWY
Mailing Address - Street 2:STE 35
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-3544
Mailing Address - Country:US
Mailing Address - Phone:806-785-7676
Mailing Address - Fax:806-785-7685
Practice Address - Street 1:3502 9TH ST STE 110
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79415-3367
Practice Address - Country:US
Practice Address - Phone:806-762-8461
Practice Address - Fax:806-761-0761
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP110475363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092939002Medicaid
85N601Medicare ID - Type Unspecified
P22568Medicare UPIN