Provider Demographics
NPI:1952378564
Name:GRAHAM, DONNA (NP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5741
Mailing Address - Country:US
Mailing Address - Phone:706-787-6922
Mailing Address - Fax:706-787-7767
Practice Address - Street 1:300 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5741
Practice Address - Country:US
Practice Address - Phone:706-787-6922
Practice Address - Fax:706-787-7767
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN136197NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0756Medicaid
GAS55041Medicare UPIN
SCNP0756Medicaid