1306545850 NPI number — SHAWNTAE GRAHAM

Table of content: SHAWNTAE GRAHAM (NPI 1306545850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306545850 NPI number — SHAWNTAE GRAHAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
SHAWNTAE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1306545850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
345 BROADMOOR WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-4290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-644-6751
Provider Business Mailing Address Fax Number:
678-759-2696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 BROADMOOR WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253-4290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-644-6751
Provider Business Practice Location Address Fax Number:
678-759-2696
Provider Enumeration Date:
02/23/2023

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: 104100000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003005071A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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