Provider Demographics
NPI:1851835441
Name:GRAHAM, SANDRA (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:CHARLENE
Other - Last Name:LEE GRAHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:2160 COLONIAL BLVD.
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:101 MCLEOD HEALTH BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4477
Practice Address - Country:US
Practice Address - Phone:843-236-4949
Practice Address - Fax:843-236-4746
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20847363L00000X, 363LF0000X
SC64997390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC30705179OtherSELECT HEALTH MEDICAID LINE OF BUSINESS
SC1851835441Medicaid
SC4924376OtherAETNA
SC7206002OtherCIGNA
SC6425288OtherUNITED HEALTHCARE
SC4924376OtherAETNA