Healthcare Provider Details

I. General information

NPI: 1780026336
Provider Name (Legal Business Name): AMITA GRAHAM CNM, WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 W CONGRESS ST
TUCSON AZ
85745-2819
US

IV. Provider business mailing address

839 W CONGRESS ST
TUCSON AZ
85745-2819
US

V. Phone/Fax

Practice location:
  • Phone: 520-309-2506
  • Fax:
Mailing address:
  • Phone: 520-309-2506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number95100740
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number10725971
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number95011742
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number236037
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: