Healthcare Provider Details

I. General information

NPI: 1760465199
Provider Name (Legal Business Name): KATHLEEN M GRAHAM CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

IV. Provider business mailing address

700 WEST AVE S
LA CROSSE WI
54601-4783
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-0940
  • Fax:
Mailing address:
  • Phone: 608-785-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2409
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License Number028008205
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: