Provider Demographics
NPI:1104657071
Name:GRAHAM, TRACY VIRGINIA
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:VIRGINIA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 NE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-1611
Mailing Address - Country:US
Mailing Address - Phone:503-267-5403
Mailing Address - Fax:
Practice Address - Street 1:11286 SE STEVENS RD # A307
Practice Address - Street 2:
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-7640
Practice Address - Country:US
Practice Address - Phone:503-267-5403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider