Provider Demographics
NPI:1730868894
Name:GRAHAM, DESIREE MARLO (PA-C)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:MARLO
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8042 BIENVILLE DR APT A102
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-7538
Mailing Address - Country:US
Mailing Address - Phone:257-801-5784
Mailing Address - Fax:
Practice Address - Street 1:3400 S CHURCH ST STE B
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37127-7218
Practice Address - Country:US
Practice Address - Phone:615-639-5515
Practice Address - Fax:615-639-5505
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN6195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant