Provider Demographics
NPI:1376120956
Name:GRAHAM, MANDY
Entity Type:Individual
Prefix:
First Name:MANDY
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 1:440 ELLIS ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97344-9731
Mailing Address - Country:US
Mailing Address - Phone:503-580-2109
Mailing Address - Fax:
Practice Address - Street 1:525 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-2834
Practice Address - Country:US
Practice Address - Phone:503-917-2083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200941991RN163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant