Healthcare Provider Details

I. General information

NPI: 1356457824
Provider Name (Legal Business Name): CYNTHIA VIRGINIA GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

IV. Provider business mailing address

14913 SE MILL PLAIN BLVD APT D25
VANCOUVER WA
98684-8241
US

V. Phone/Fax

Practice location:
  • Phone: 360-571-3084
  • Fax:
Mailing address:
  • Phone: 360-609-7759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDT10005386
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: