Provider Demographics
NPI:1619550423
Name:GRAHAM, CASSIDY LYNN (AGACNP)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:LYNN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1251 STRASSNER DR UNIT 2313
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-1881
Mailing Address - Country:US
Mailing Address - Phone:309-319-3368
Mailing Address - Fax:
Practice Address - Street 1:1036 TOWN AND COUNTRY CROSSING DR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-0610
Practice Address - Country:US
Practice Address - Phone:314-833-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2021005553363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care