Provider Demographics
NPI:1487750675
Name:KNUST GRAICHEN, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KNUST GRAICHEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:WRENTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02093-1733
Mailing Address - Country:US
Mailing Address - Phone:508-384-2844
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:BRIGHAM & WOMEN'S HOSPITAL, BREAST CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-8111
Practice Address - Fax:617-264-6344
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA159259363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP31639Medicare ID - Type Unspecified
MANP3264Medicare UPIN