Basic Information
Provider Information | |||||||||
NPI: | 1366615106 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAHAM | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | R.N. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2660 N HIGHWAY 17 | ||||||||
Address2: |   | ||||||||
City: | MURDOCK | ||||||||
State: | KS | ||||||||
PostalCode: | 671118924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3166852221 | ||||||||
FaxNumber: | 3166815599 | ||||||||
Practice Location | |||||||||
Address1: | 2660 N HIGHWAY 17 | ||||||||
Address2: |   | ||||||||
City: | MURDOCK | ||||||||
State: | KS | ||||||||
PostalCode: | 671118924 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3166513661 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2008 | ||||||||
LastUpdateDate: | 06/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC0200X | 13-80009-062 | KS | Y |   | Nursing Service Providers | Registered Nurse | Critical Care Medicine |
No ID Information.