Healthcare Provider Details

I. General information

NPI: 1407100357
Provider Name (Legal Business Name): KATHLEEN POWERS GRAHAM NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15700 37TH AVE N STE 300
PLYMOUTH MN
55446-3661
US

IV. Provider business mailing address

1973 SLOAN PL
MAPLEWOOD MN
55117-2084
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1145
  • Fax:
Mailing address:
  • Phone: 612-871-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberG0712013
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberA0712144
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: