Healthcare Provider Details

I. General information

NPI: 1467582197
Provider Name (Legal Business Name): TERESA KEM GRAHAM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 LEWIS AVE
TEMPERANCE MI
48182-9583
US

IV. Provider business mailing address

225 RIVERSIDE AVE
ADRIAN MI
49221-1539
US

V. Phone/Fax

Practice location:
  • Phone: 734-847-3802
  • Fax: 734-847-3418
Mailing address:
  • Phone: 517-263-1800
  • Fax: 517-263-1866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-09190
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704198775
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: