Provider Demographics
NPI:1093315095
Name:GRAHAM, SHANA P (CERTIFIED NURSING AI)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:P
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CERTIFIED NURSING AI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8308 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4003
Mailing Address - Country:US
Mailing Address - Phone:317-531-1550
Mailing Address - Fax:
Practice Address - Street 1:8308 E 11TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4003
Practice Address - Country:US
Practice Address - Phone:317-531-1550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN376K00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No376K00000XNursing Service Related ProvidersNurse's Aide