Provider Demographics
NPI:1760698674
Name:GRAHAM, POLLY RAE (MBA, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:RAE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MBA, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6395 115TH ST
Mailing Address - Street 2:
Mailing Address - City:BLUE GRASS
Mailing Address - State:IA
Mailing Address - Zip Code:52726-9609
Mailing Address - Country:US
Mailing Address - Phone:563-381-4113
Mailing Address - Fax:563-421-1714
Practice Address - Street 1:1227 E RUSHOLME ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2459
Practice Address - Country:US
Practice Address - Phone:563-421-6943
Practice Address - Fax:563-421-6959
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00732133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered