MEDICARE: KANISHA GRAHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247ZC0005X	Clinical Laboratory Director (Non-physician)

General Provider Information

NPI Number	:	1639817471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KANISHA GRAHAM

Provider Business Mailing Address
First Line	:	6237 PRESIDENTIAL CT STE 140
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3508
Country	:	US
Telephone Number	:	877-202-3530
Fax Number	:	877-772-5877

Provider Business Practice Location Address
First Line	:	6237 PRESIDENTIAL CT STE 140
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-3508
Country	:	US
Telephone Number	:	877-202-3530
Fax Number	:	877-772-5877

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2022
Last Update Date	:	05/23/2022

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