=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356853451
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE ANISE GRAHAM LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2017
-----------------------------------------------------
Last Update Date | 10/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 MATSUNAYE DR
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-394-1357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 MATSUNAYE DR
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-394-1357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 330386
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------