Provider Demographics
NPI:1578076659
Name:GRAHAM, DENISHA (BS, IBCLC)
Entity Type:Individual
Prefix:
First Name:DENISHA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:BS, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N WHEELER ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-1439
Mailing Address - Country:US
Mailing Address - Phone:405-201-2473
Mailing Address - Fax:
Practice Address - Street 1:2701 N WHEELER ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-1439
Practice Address - Country:US
Practice Address - Phone:405-201-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-10
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 174400000X
L-127057174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174400000XOther Service ProvidersSpecialist