Healthcare Provider Details

I. General information

NPI: 1235911801
Provider Name (Legal Business Name): MARIANNE GRAHAM RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 WEATHERED ST
IRVING TX
75062-6642
US

IV. Provider business mailing address

1106 WEATHERED ST
IRVING TX
75062-6642
US

V. Phone/Fax

Practice location:
  • Phone: 661-644-5965
  • Fax:
Mailing address:
  • Phone: 661-644-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-17122
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: