Healthcare Provider Details

I. General information

NPI: 1609707553
Provider Name (Legal Business Name): CERRISSA MICHELLE GRAHAM I LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 MONROE ST
STOWE PA
19464-6717
US

IV. Provider business mailing address

223 MONROE ST
STOWE PA
19464-6717
US

V. Phone/Fax

Practice location:
  • Phone: 484-941-0516
  • Fax: 610-705-8945
Mailing address:
  • Phone: 484-941-0516
  • Fax: 610-705-8945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN323466
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: