Provider Demographics
NPI:1922692102
Name:GRAHAM, AUDREY LYNN
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:LYNN
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 1:1841 LASCASSAS PIKE APT I130
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37130-0644
Mailing Address - Country:US
Mailing Address - Phone:615-318-7617
Mailing Address - Fax:
Practice Address - Street 1:1841 LASCASSAS PIKE APT I130
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-0644
Practice Address - Country:US
Practice Address - Phone:615-318-7617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000013238225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist