Provider Demographics
NPI:1295238343
Name:BURGESS-GRAHAM, LEVADA CHANTE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:LEVADA
Middle Name:CHANTE
Last Name:BURGESS-GRAHAM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 TRILLIUM LN
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-8386
Mailing Address - Country:US
Mailing Address - Phone:706-483-4784
Mailing Address - Fax:
Practice Address - Street 1:84 TRILLIUM LN
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8386
Practice Address - Country:US
Practice Address - Phone:706-483-4784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195974363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily