Provider Demographics
NPI:1902105760
Name:GRAHAM, ANGELA D (CPNP-AC)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:D
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:MRS
Other - First Name:ANGELA
Other - Middle Name:D
Other - Last Name:JOACHIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-AC
Mailing Address - Street 1:210 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2497
Mailing Address - Country:US
Mailing Address - Phone:309-647-5240
Mailing Address - Fax:309-649-5128
Practice Address - Street 1:210 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2497
Practice Address - Country:US
Practice Address - Phone:309-647-5240
Practice Address - Fax:309-649-5128
Is Sole Proprietor?:No
Enumeration Date:2011-03-19
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008727363LP0222X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care