Provider Demographics
NPI:1265842629
Name:GRAHAM, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:978 E 48TH ST
Mailing Address - Street 2:1ST FL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-6604
Mailing Address - Country:US
Mailing Address - Phone:718-759-7267
Mailing Address - Fax:
Practice Address - Street 1:978 E 48TH ST
Practice Address - Street 2:1ST FL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-6604
Practice Address - Country:US
Practice Address - Phone:718-759-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317968164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse