Provider Demographics
NPI:1720530629
Name:GRAHAM, KELLY (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:DAWN
Other - Last Name:DEMARCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-689-5104
Mailing Address - Fax:757-689-2717
Practice Address - Street 1:213 RIVER WALK PKWY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-6893
Practice Address - Country:US
Practice Address - Phone:757-983-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173581363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1720530629Medicaid
VA1720530629OtherMULTIPLAN
VA1720530629OtherCORVEL
VA1720530629OtherHUMANA
VA1720530629OtherUSA MANAGED CARE
VA1720530629OtherVIRGINIA PREMIER HEALTH PLAN
VA1720530629OtherTRICARE/CHAMPUS
VA1720530629OtherOPTIMA HEALTH
NC1720530629Medicaid
VA1720530629OtherUSA MANAGED CARE