Provider Demographics
NPI:1952297541
Name:GRAHAM, COLEEN FENNA (RN)
Entity type:Individual
Prefix:
First Name:COLEEN
Middle Name:FENNA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12940 79TH PL
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:WI
Mailing Address - Zip Code:53104-8922
Mailing Address - Country:US
Mailing Address - Phone:801-380-3159
Mailing Address - Fax:
Practice Address - Street 1:12940 79TH PL
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:WI
Practice Address - Zip Code:53104-8922
Practice Address - Country:US
Practice Address - Phone:801-380-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-18
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21327922163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health