Healthcare Provider Details

I. General information

NPI: 1497587729
Provider Name (Legal Business Name): NICOLE LEANN GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2024
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MARKET ST
INDIANAPOLIS IN
46202-3831
US

IV. Provider business mailing address

3400 LAFAYETTE RD STE 200
INDIANAPOLIS IN
46222-1147
US

V. Phone/Fax

Practice location:
  • Phone: 317-291-7422
  • Fax:
Mailing address:
  • Phone: 317-291-7422
  • Fax: 317-291-7433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number28275000A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71017022A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: