Healthcare Provider Details

I. General information

NPI: 1730720343
Provider Name (Legal Business Name): BROOKE GRAHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2019
Last Update Date: 10/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 CARLTON ST
BUFFALO NY
14204-1126
US

IV. Provider business mailing address

121 CAMPUS DR E
AMHERST NY
14226-3774
US

V. Phone/Fax

Practice location:
  • Phone: 716-816-3803
  • Fax:
Mailing address:
  • Phone: 585-943-9889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number6882921
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: