Provider Demographics
NPI:1548374879
Name:GRAHAM, TINA S (APRN)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:S
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 90039
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9039
Mailing Address - Country:US
Mailing Address - Phone:270-796-8800
Mailing Address - Fax:270-796-9328
Practice Address - Street 1:427 US 31W BYP
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1703
Practice Address - Country:US
Practice Address - Phone:270-796-8800
Practice Address - Fax:270-796-9328
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3863P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000278632OtherANTHEM
KY78009776Medicaid
KY0686702Medicare ID - Type Unspecified
KY78009776Medicaid