Provider Demographics
NPI:1467287136
Name:GRAHAM, MASHAWN
Entity type:Individual
Prefix:MRS
First Name:MASHAWN
Middle Name:
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 1:2759 DELK RD SE STE 1044
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8847
Mailing Address - Country:US
Mailing Address - Phone:202-246-1022
Mailing Address - Fax:
Practice Address - Street 1:2759 DELK RD SE STE 1044
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8847
Practice Address - Country:US
Practice Address - Phone:202-246-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071039687172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver