Healthcare Provider Details

I. General information

NPI: 1154813863
Provider Name (Legal Business Name): BENNET GRAHAM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2018
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 S COULTER ST
AMARILLO TX
79106-1786
US

IV. Provider business mailing address

1400 S COULTER ST
AMARILLO TX
79106-1786
US

V. Phone/Fax

Practice location:
  • Phone: 806-414-9558
  • Fax: 806-354-5561
Mailing address:
  • Phone: 806-414-9558
  • Fax: 806-354-5561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberAP137643
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberAP137643
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: