Healthcare Provider Details

I. General information

NPI: 1679188684
Provider Name (Legal Business Name): LAVONNA SUE GRAHAM CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GEORGE ST
BECKLEY WV
25801-2648
US

IV. Provider business mailing address

PO BOX 585
FAIRDALE WV
25839-0585
US

V. Phone/Fax

Practice location:
  • Phone: 304-929-2669
  • Fax:
Mailing address:
  • Phone: 304-894-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number76652
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: