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General NPI Number Information
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NPI Number | 1265550875
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Entity Type | Individual
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Provider Name | TRACIE RENEE GRAHAM O.T.
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Gender | Female
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 07/09/2007
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Provider Practice Location Address
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Address Line | 413 W. TYLER COVE
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City | WEST MEMPHIS
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State | AR
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Zip | 72301
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Country | US
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Telephone | 870-733-1200
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Fax | 870-732-3269
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Provider Business Mailing Address
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Address Line | 4734 BETHAY DR
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City | MEMPHIS
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State | TN
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Zip | 38125-5700
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Country | US
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Telephone | 901-494-3710
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Fax | 870-733-1200
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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 | 174400000X
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Taxonomy Name | Specialist
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License Number | OTR1280
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License Number State | AR
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