Provider Demographics
NPI:1639817471
Name:GRAHAM, KANISHA
Entity Type:Individual
Prefix:
First Name:KANISHA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6237 PRESIDENTIAL CT STE 140
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3508
Mailing Address - Country:US
Mailing Address - Phone:877-202-3530
Mailing Address - Fax:877-772-5877
Practice Address - Street 1:6237 PRESIDENTIAL CT STE 140
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3508
Practice Address - Country:US
Practice Address - Phone:877-202-3530
Practice Address - Fax:877-772-5877
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician