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General NPI Number Information
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NPI Number | 1790277184
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Entity Type | Individual
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Provider Name | KERRY GRAHAM
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Gender | Female
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Dates
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Enumeration Date | 06/01/2018
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Last Update Date | 06/01/2018
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Provider Practice Location Address
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Address Line | 1853 R W BERENDS DR SW
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City | WYOMING
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State | MI
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Zip | 49519-4955
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Country | US
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Telephone | 616-466-8012
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Fax |
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Provider Business Mailing Address
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Address Line | 1814 WOODWARD AVE
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City | KALAMAZOO
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State | MI
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Zip | 49007-1764
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 4703105730
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License Number State | PA
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