Provider Demographics
NPI:1699108621
Name:GRAHAM, TONIA LANETTE (FNP)
Entity type:Individual
Prefix:
First Name:TONIA
Middle Name:LANETTE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20449 N LAKE PLEASANT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-2707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20449 N LAKE PLEASANT RD STE 101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382
Practice Address - Country:US
Practice Address - Phone:602-570-5587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP5186363LF0000X
AZRN088868163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ852024Medicaid
AZZ162579Medicare PIN
AZZ161464Medicare PIN