Healthcare Provider Details

I. General information

NPI: 1043263296
Provider Name (Legal Business Name): SUSAN R GRAHAM C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 191 HOSPITAL DRIVE
CHINLE AZ
86503
US

IV. Provider business mailing address

PO BOX 1569
CHINLE AZ
86503-1569
US

V. Phone/Fax

Practice location:
  • Phone: 518-944-9660
  • Fax:
Mailing address:
  • Phone: 518-944-9660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number000570
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: