Provider Demographics
NPI:1285809673
Name:GRAHAM, NICOLE RENEE (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RENEE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:EDMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:901 NE INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5544
Mailing Address - Country:US
Mailing Address - Phone:816-347-3223
Mailing Address - Fax:
Practice Address - Street 1:901 NE INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-5544
Practice Address - Country:US
Practice Address - Phone:816-347-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT01-524482084P0800X
FLTRN157062084P0800X
FLME1114142084P0804X
390200000X
MO20160330902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program