Provider Demographics
NPI:1285078287
Name:GRAHAM, DAVEDA JUNE (CRNP)
Entity type:Individual
Prefix:
First Name:DAVEDA
Middle Name:JUNE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 JERRY RD
Mailing Address - Street 2:
Mailing Address - City:BLACKSTONE
Mailing Address - State:VA
Mailing Address - Zip Code:23824-2912
Mailing Address - Country:US
Mailing Address - Phone:267-588-2328
Mailing Address - Fax:
Practice Address - Street 1:25 S UNION ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4221
Practice Address - Country:US
Practice Address - Phone:804-957-9601
Practice Address - Fax:804-947-5859
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-20
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016107363LA2200X
VA0001320979163W00000X
PARN596948163W00000X
VA0024187418363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse