Provider Demographics
NPI:1720736788
Name:GRAHAM, LISA MICHELLE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
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 1:1528 E 950 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:62438-4029
Mailing Address - Country:US
Mailing Address - Phone:217-690-8288
Mailing Address - Fax:
Practice Address - Street 1:815 N LONG ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62565-1172
Practice Address - Country:US
Practice Address - Phone:217-820-9496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3747A0650X
3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider