Provider Demographics
NPI:1487381950
Name:GRAHAM, JIYA L
Entity type:Individual
Prefix:
First Name:JIYA
Middle Name:L
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 1:8420 CHADWOOD LANE EAST DR APT 1C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3594
Mailing Address - Country:US
Mailing Address - Phone:260-515-7887
Mailing Address - Fax:
Practice Address - Street 1:8420 CHADWOOD LANE EAST DR APT 1C
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-3594
Practice Address - Country:US
Practice Address - Phone:260-515-7887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor