Provider Demographics
NPI:1619997442
Name:GRAHAM, LESLIE LYNNE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:LYNNE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 GREEN RIDGE DR.
Mailing Address - Street 2:
Mailing Address - City:WICKLIFFE
Mailing Address - State:OH
Mailing Address - Zip Code:44092
Mailing Address - Country:US
Mailing Address - Phone:440-347-9653
Mailing Address - Fax:
Practice Address - Street 1:696 DICKERSON
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095
Practice Address - Country:US
Practice Address - Phone:440-943-0391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN092731164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2434Medicaid
OH2350638Medicaid