Provider Demographics
NPI:1588913750
Name:GRAHAM, JAMIE LYNN (FNP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:WAGVESPACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 952639
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31192-2639
Mailing Address - Country:US
Mailing Address - Phone:800-684-0857
Mailing Address - Fax:405-844-1794
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:225-765-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2317245Medicaid
LA254996YH83Medicare PIN