Provider Demographics
NPI:1265835607
Name:GRAHAM, MARY ANNA (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 MALDEN AVE
Mailing Address - Street 2:PALENVILLE
Mailing Address - City:PALENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12463-2511
Mailing Address - Country:US
Mailing Address - Phone:518-678-9292
Mailing Address - Fax:
Practice Address - Street 1:92 MALDEN AVE
Practice Address - Street 2:PALENVILLE
Practice Address - City:PALENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12463-2511
Practice Address - Country:US
Practice Address - Phone:518-678-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153450164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse