MEDICARE: DEBRA JEANNE GRAHAM DNP

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	163W00000X	Registered Nurse	657712	CA
2	163W00000X	Registered Nurse	136486	TN
3	363LP0200X	Pediatric Nurse Practitioner	15657	CA
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	15657	CA

General Provider Information

NPI Number	:	1790757623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA JEANNE GRAHAM DNP

Provider Business Mailing Address
First Line	:	PO BOX 1770
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91944-1770
Country	:	US
Telephone Number	:	619-464-1165
Fax Number	:	619-567-1011

Provider Business Practice Location Address
First Line	:	4537 COLLEGE AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-4010
Country	:	US
Telephone Number	:	619-229-1895
Fax Number	:	619-229-1837

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

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/16/2013

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