Provider Demographics
NPI:1083762116
Name:GRAHAM, NIKKY (RD,LD)
Entity Type:Individual
Prefix:MRS
First Name:NIKKY
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 PERKINSWOOD BLVD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-4410
Mailing Address - Country:US
Mailing Address - Phone:330-392-0220
Mailing Address - Fax:
Practice Address - Street 1:1150 NILES CORTLAND RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-3510
Practice Address - Country:US
Practice Address - Phone:330-544-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00810361133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered