Provider Demographics
NPI:1881878064
Name:GRAHAM, MARIE A (APN)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:A
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 WEST BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NO LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114
Mailing Address - Country:US
Mailing Address - Phone:501-374-1153
Mailing Address - Fax:501-374-6213
Practice Address - Street 1:636 WEST BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NO LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114
Practice Address - Country:US
Practice Address - Phone:501-374-1153
Practice Address - Fax:501-374-6213
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARATP-000116363LA2100X
ARA003059363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARATP000116OtherLICENSE