Provider Demographics
NPI:1356968390
Name:GRAHAM, KENDRA MAE (PA)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:MAE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 LITTLE MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-8752
Mailing Address - Country:US
Mailing Address - Phone:360-428-2622
Mailing Address - Fax:360-428-3941
Practice Address - Street 1:2101 LITTLE MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-8752
Practice Address - Country:US
Practice Address - Phone:360-428-2622
Practice Address - Fax:360-428-3941
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61085104363A00000X
WAPA60185104363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant