Healthcare Provider Details

I. General information

NPI: 1730549510
Provider Name (Legal Business Name): KATHRYN GRAHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 FRANKLIN AVE STE 4500
NORMAL IL
61761
US

IV. Provider business mailing address

1302 FRANKLIN AVE STE 4500
NORMAL IL
61761-3593
US

V. Phone/Fax

Practice location:
  • Phone: 309-556-8300
  • Fax: 309-556-8293
Mailing address:
  • Phone: 309-556-8300
  • Fax: 309-556-8293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209013965
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: