Provider Demographics
NPI:1205525235
Name:GRAHAM, JENNIFER ELISE (RN FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELISE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 W K ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2414
Mailing Address - Country:US
Mailing Address - Phone:707-246-2292
Mailing Address - Fax:
Practice Address - Street 1:1387 E 2ND ST
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-2836
Practice Address - Country:US
Practice Address - Phone:707-377-1005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023957363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner