Provider Demographics
NPI:1811995103
Name:GRAHAM, MARY LOU (NP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOU
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:45 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06052-1312
Mailing Address - Country:US
Mailing Address - Phone:860-612-0432
Mailing Address - Fax:860-612-0087
Practice Address - Street 1:45 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1312
Practice Address - Country:US
Practice Address - Phone:860-612-0432
Practice Address - Fax:860-612-0087
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003146363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2070747OtherCIGNA
CT112425000OtherCAQH
500002055OtherMEDICARE PTAN