Provider Demographics
NPI:1417191511
Name:GRAHAM, ANDREA MAXINE
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:MAXINE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:MAXINE
Other - Last Name:GRAHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:11430 178TH PL
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-1410
Mailing Address - Country:US
Mailing Address - Phone:718-558-5847
Mailing Address - Fax:
Practice Address - Street 1:11430 178TH PL
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-1410
Practice Address - Country:US
Practice Address - Phone:718-558-5847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY460102251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care