Provider Demographics
NPI:1649490665
Name:GRAHAM, SHANNON WILSON (RN,CNS)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:WILSON
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RN,CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 QUAIL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DEL RIO
Mailing Address - State:TX
Mailing Address - Zip Code:78840-2133
Mailing Address - Country:US
Mailing Address - Phone:830-778-1509
Mailing Address - Fax:830-778-1509
Practice Address - Street 1:400 QUAIL CREEK DR
Practice Address - Street 2:
Practice Address - City:DEL RIO
Practice Address - State:TX
Practice Address - Zip Code:78840-2133
Practice Address - Country:US
Practice Address - Phone:830-778-1509
Practice Address - Fax:830-778-1509
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX504390364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health