1649243619 NPI number — JULIE A GRAHAM PMHNP

Table of content: JULIE A GRAHAM PMHNP (NPI 1649243619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649243619 NPI number — JULIE A GRAHAM PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
JULIE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649243619
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 W AGENCY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BURLINGTON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52655-1667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-768-5858
Provider Business Mailing Address Fax Number:
319-752-4653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEOKUK
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52632-3452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-524-5734
Provider Business Practice Location Address Fax Number:
319-524-5758
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  142186 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: G095717 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 429098114 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com