Healthcare Provider Details

I. General information

NPI: 1033365473
Provider Name (Legal Business Name): SHAWNA DEE GRAYHAM STATE LICENSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2008
Last Update Date: 12/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W MAIN ST
RUSSELLVILLE AR
72801-2719
US

IV. Provider business mailing address

1609 W MAIN ST
RUSSELLVILLE AR
72801-2719
US

V. Phone/Fax

Practice location:
  • Phone: 479-967-7538
  • Fax: 479-968-9077
Mailing address:
  • Phone: 479-967-7538
  • Fax: 479-968-9077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAR590
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: