Provider Demographics
NPI:1497075956
Name:GRAHAM, CYNTHIA MARIE (OTHER)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:OTHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 W BURNSVILLE PKWY
Mailing Address - Street 2:#138
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2527
Mailing Address - Country:US
Mailing Address - Phone:952-890-5607
Mailing Address - Fax:952-469-8457
Practice Address - Street 1:201 W BURNSVILLE PKWY
Practice Address - Street 2:#138
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2527
Practice Address - Country:US
Practice Address - Phone:952-890-5607
Practice Address - Fax:952-469-8457
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN09328513174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist