Basic Information
| Provider Information | |||||||||
| NPI: | 1619404928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JENINE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APRN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11187 WOODS EDGE AVE | ||||||||
| Address2: | |||||||||
| City: | BECKER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553084553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633703515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202402830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2017 | ||||||||
| LastUpdateDate: | 05/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5005 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.