Basic Information
| Provider Information | |||||||||
| NPI: | 1851619886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUE GRAHAM | ||||||||
| FirstName: | VALENCIA | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLUE | ||||||||
| OtherFirstName: | VALENCIA | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7200 NORMANDY BLVD STE 20 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322056271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043788520 | ||||||||
| FaxNumber: | 9043788570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2010 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ANP9255707 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.