Healthcare Provider Details

I. General information

NPI: 1336693266
Provider Name (Legal Business Name): VANESSA BRISTOW GRAHAM FNP, PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7259 WATERWHEEL ST SW
CONCORD NC
28025-6723
US

IV. Provider business mailing address

7259 WATERWHEEL ST SW
CONCORD NC
28025-6723
US

V. Phone/Fax

Practice location:
  • Phone: 704-267-6905
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF07161019
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: