Provider Demographics
NPI:1578361630
Name:GRAHAM, BEVERLY (LPN)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4077
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06147-4077
Mailing Address - Country:US
Mailing Address - Phone:860-990-7757
Mailing Address - Fax:
Practice Address - Street 1:511 E COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2506
Practice Address - Country:US
Practice Address - Phone:413-733-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN93726164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse