Healthcare Provider Details

I. General information

NPI: 1962607382
Provider Name (Legal Business Name): SANDRA L GRAHAM RNC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2007
Last Update Date: 11/09/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4915 42ND AVE N
ROBBINSDALE MN
55422-1730
US

IV. Provider business mailing address

6224 CAVELL AVE N
BROOKLYN PARK MN
55428-2606
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-1316
  • Fax:
Mailing address:
  • Phone: 763-535-4634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 067255-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: