Healthcare Provider Details

I. General information

NPI: 1982660395
Provider Name (Legal Business Name): KIMBERLY GRAHAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 9TH ST STE 110
LUBBOCK TX
79415-3367
US

IV. Provider business mailing address

5219 CITY BANK PKWY STE 35
LUBBOCK TX
79407-3544
US

V. Phone/Fax

Practice location:
  • Phone: 806-762-8461
  • Fax: 806-761-0761
Mailing address:
  • Phone: 806-785-7676
  • Fax: 806-785-7685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP110475
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: