Individual
MS. MARY LOU GRAHAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
45 RUSSELL ST, NEW BRITAIN, CT 06052-1312
(860) 612-0432
(860) 612-0087
Mailing address
45 RUSSELL ST, NEW BRITAIN, CT 06052-1312
(860) 612-0432
(860) 612-0087
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
003146
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
112425000
CAQH
CT
01
—
2070747
CIGNA
CT
01
—
500002055
MEDICARE PTAN
—
Enumeration date
07/11/2005
Last updated
10/25/2023
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