Provider Demographics
NPI:1720571631
Name:GRAHAM, ROXANN (RN)
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-0386
Mailing Address - Country:US
Mailing Address - Phone:517-339-2220
Mailing Address - Fax:
Practice Address - Street 1:1390 HICKORY ISLAND DR
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840-8944
Practice Address - Country:US
Practice Address - Phone:517-339-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704297919163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse