Healthcare Provider Details

I. General information

NPI: 1497036099
Provider Name (Legal Business Name): JACKLYNN REYNA GRAHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDDAC-JAPAN UNIT 45011
APO AP
96343-5011
US

IV. Provider business mailing address

UNIT 45013 BOX 3193
APO AP
96338
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-4128
  • Fax:
Mailing address:
  • Phone: 305-424-6089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number115334
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: