1588900682 NPI number — MRS. SHELLEY MONTINA GRAHAM PTA

Table of content: MRS. SHELLEY MONTINA GRAHAM PTA (NPI 1588900682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588900682 NPI number — MRS. SHELLEY MONTINA GRAHAM PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
SHELLEY
Provider Middle Name:
MONTINA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588900682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17251 LAGUNA VISTA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMARILLO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79119-7740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-499-3766
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 RANGER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEREFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79045-2812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-364-0669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2012

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: 225200000X , with the licence number:  2040400 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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