Provider Demographics
NPI:1437563111
Name:GRAHAM, MARY (LVN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:13417 OROURKE DR
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-5682
Mailing Address - Country:US
Mailing Address - Phone:575-640-5597
Mailing Address - Fax:
Practice Address - Street 1:13417 OROURKE DR
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-5682
Practice Address - Country:US
Practice Address - Phone:575-640-5597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210586164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse