MEDICARE: GLORIA L GRAHAM NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	A01560	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275549172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA L GRAHAM NP

Provider Business Mailing Address
First Line	:	2921 HWY 77 S
Second Line	:	SUITE 20
City	:	MARION
State	:	AR
Zip	:	72364-2367
Country	:	US
Telephone Number	:	870-739-5311
Fax Number	:	870-739-5542

Provider Business Practice Location Address
First Line	:	2921 HWY 77 S
Second Line	:	SUITE 20
City	:	MARION
State	:	AR
Zip	:	72364-2367
Country	:	US
Telephone Number	:	870-739-5311
Fax Number	:	870-739-5542

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	09/26/2011

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