Healthcare Provider Details

I. General information

NPI: 1346944584
Provider Name (Legal Business Name): EVAN NICOLE GRAHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3366 HIGHWAY 42 S STE 110
LOCUST GROVE GA
30248-3039
US

IV. Provider business mailing address

8954 HOSPITAL DR
DOUGLASVILLE GA
30134-2272
US

V. Phone/Fax

Practice location:
  • Phone: 770-898-4339
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number109938
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: