Basic Information
| Provider Information | |||||||||
| NPI: | 1760021539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 FRANK ST | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064054645 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 477 BOSTON POST RD | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064773548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4752099130 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2019 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 8667 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 8667 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.