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General NPI Number Information
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NPI Number | 1225836398
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Entity Type | Individual
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Provider Name | SALLY GRAHAM
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Gender |
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Dates
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Enumeration Date | 03/05/2025
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Last Update Date | 03/05/2025
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Provider Practice Location Address
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Address Line | 13503 S 30TH ST
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City | BELLEVUE
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State | NE
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Zip | 68123-4632
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Country | US
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Telephone | 402-708-8636
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Fax |
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Provider Business Mailing Address
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Address Line | 4715 S 132ND ST
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City | OMAHA
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State | NE
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Zip | 68137-1899
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Country | US
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Telephone | 402-708-8636
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State |
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