Provider Demographics
NPI:1588265334
Name:GRAHAM, MANETTE ELAINE (PRESIDENT OF THE LLC)
Entity type:Individual
Prefix:MS
First Name:MANETTE
Middle Name:ELAINE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PRESIDENT OF THE LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 EAST CAYUGA ST.
Mailing Address - Street 2:SAME
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610
Mailing Address - Country:US
Mailing Address - Phone:813-665-5536
Mailing Address - Fax:
Practice Address - Street 1:1717 E CAYUGA ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-6025
Practice Address - Country:US
Practice Address - Phone:813-665-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health