Provider Demographics
NPI:1790867380
Name:GRAHAM, JIMMY LEE
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:LEE
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13901 SE 71ST PLACE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73115
Mailing Address - Country:US
Mailing Address - Phone:405-386-4623
Mailing Address - Fax:
Practice Address - Street 1:13901 SE 71ST PLACE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73115
Practice Address - Country:US
Practice Address - Phone:405-386-4623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide