Provider Demographics
NPI:1700879020
Name:GRAHN, JODY (NP C)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:GRAHN
Suffix:
Gender:F
Credentials:NP C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3117 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304-4813
Mailing Address - Country:US
Mailing Address - Phone:716-297-2052
Mailing Address - Fax:716-215-6170
Practice Address - Street 1:251 EAST AVE
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-3825
Practice Address - Country:US
Practice Address - Phone:716-257-1248
Practice Address - Fax:716-215-6170
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA136905363LA2200X
NY310425363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06835221OtherMEDICAID
GA50BBHHJMedicare PIN
GAP29398Medicare UPIN