Healthcare Provider Details

I. General information

NPI: 1982938726
Provider Name (Legal Business Name): NICOLE C GRAHAM ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2009
Last Update Date: 09/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

839 W ROOSEVELT RD ATHLETIC TRAINING
CHICAGO IL
60608-1530
US

IV. Provider business mailing address

3435 N ELAINE PL APT #2R
CHICAGO IL
60657-2077
US

V. Phone/Fax

Practice location:
  • Phone: 312-993-2043
  • Fax:
Mailing address:
  • Phone: 847-668-5597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096003262
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: