Provider Demographics
NPI:1669256236
Name:GRAHAM, BEVERLY DIANE
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:DIANE
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 1:417 1/2 N WHITEWOMAN ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1064
Mailing Address - Country:US
Mailing Address - Phone:740-202-0981
Mailing Address - Fax:
Practice Address - Street 1:417 1/2 N WHITEWOMAN ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1064
Practice Address - Country:US
Practice Address - Phone:740-202-0981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRH676792172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver