Healthcare Provider Details

I. General information

NPI: 1457337149
Provider Name (Legal Business Name): MARIETTA GRAHAM-LOPEZ RN, CS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E CHERRY ST
TROY MO
63379-1429
US

IV. Provider business mailing address

900 E CHERRY ST
TROY MO
63379-1429
US

V. Phone/Fax

Practice location:
  • Phone: 636-528-8585
  • Fax: 636-528-8430
Mailing address:
  • Phone: 636-528-8585
  • Fax: 636-528-8430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number083458
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: