Healthcare Provider Details

I. General information

NPI: 1568229425
Provider Name (Legal Business Name): KATHY RENE' GRAHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2024
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 JOE FRANK HARRIS PKWY SE
CARTERSVILLE GA
30120-2129
US

IV. Provider business mailing address

11 A C DR
DALLAS GA
30132-0215
US

V. Phone/Fax

Practice location:
  • Phone: 470-490-2142
  • Fax: 470-490-2140
Mailing address:
  • Phone: 470-330-6399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN-NP139977
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: