Provider Demographics
NPI:1700473238
Name:GRAHAM, KEISHA
Entity Type:Individual
Prefix:
First Name:KEISHA
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 1:16240 WANN RD
Mailing Address - Street 2:
Mailing Address - City:SULPHUR SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72768-9036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3895 GEORGE ANDERSON RD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-8251
Practice Address - Country:US
Practice Address - Phone:479-521-1532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL060680164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse