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General NPI Number Information
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NPI Number | 1982938726
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Entity Type | Individual
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Provider Name | NICOLE C GRAHAM ATC, LAT
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Gender | Female
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Dates
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Enumeration Date | 09/27/2009
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Last Update Date | 09/19/2014
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Provider Practice Location Address
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Address Line | 839 W ROOSEVELT RD ATHLETIC TRAINING
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City | CHICAGO
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State | IL
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Zip | 60608-1530
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Country | US
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Telephone | 312-993-2043
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Fax |
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Provider Business Mailing Address
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Address Line | 3435 N ELAINE PL APT #2R
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City | CHICAGO
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State | IL
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Zip | 60657-2077
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Country | US
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Telephone | 847-668-5597
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096003262
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License Number State | IL
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