Provider Demographics
NPI:1982009288
Name:GRAHAM, KATIE MARIE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:MARIE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1980 TAMARACK RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1363
Mailing Address - Country:US
Mailing Address - Phone:220-564-7520
Mailing Address - Fax:
Practice Address - Street 1:1980 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1363
Practice Address - Country:US
Practice Address - Phone:220-564-7520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.16759363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0113641Medicaid