1467410969 NPI number — DR. AMY RENAE GRAHAM DPT

Table of content: DR. AMY RENAE GRAHAM DPT (NPI 1467410969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467410969 NPI number — DR. AMY RENAE GRAHAM DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
AMY
Provider Middle Name:
RENAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOODWARD
Provider Other First Name:
AMY
Provider Other Middle Name:
RENAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467410969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3075 GOODMAN RD E STE 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38672-6359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-349-9288
Provider Business Mailing Address Fax Number:
662-349-9289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3075 GOODMAN RD E STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38672-6359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-349-9288
Provider Business Practice Location Address Fax Number:
662-349-9289
Provider Enumeration Date:
05/03/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT7982 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT3683 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)