=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952071011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ANN GRAHAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2021
-----------------------------------------------------
Last Update Date | 10/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13001 NORTH, US-69
-----------------------------------------------------
City | ATOKA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-334-6737
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 S JEROME ST
-----------------------------------------------------
City | COALGATE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74538-1226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 204183
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------