Provider Demographics
NPI:1336387653
Name:GRAHAM, REBECCA RAE (CRNA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:RAE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:RAE
Other - Last Name:SELECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16001 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4818
Mailing Address - Country:US
Mailing Address - Phone:248-849-5806
Mailing Address - Fax:248-849-5489
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-5806
Practice Address - Fax:248-849-5489
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered