Provider Demographics
NPI:1689943789
Name:GRAHAM, HEIDI R (RD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:R
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 6TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1916
Mailing Address - Country:US
Mailing Address - Phone:541-812-4530
Mailing Address - Fax:541-812-4004
Practice Address - Street 1:1046 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1916
Practice Address - Country:US
Practice Address - Phone:541-812-4530
Practice Address - Fax:541-812-4004
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-000875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered