Healthcare Provider Details

I. General information

NPI: 1356135180
Provider Name (Legal Business Name): SADE SEQUAN GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 04/07/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 COUNTRY CLUB DR STE 240
STOCKBRIDGE GA
30281-7339
US

IV. Provider business mailing address

410 ARTHURS LN
COVINGTON GA
30016-7415
US

V. Phone/Fax

Practice location:
  • Phone: 770-810-6922
  • Fax: 844-905-1406
Mailing address:
  • Phone: 330-322-9507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN309667
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: