Provider Demographics
NPI:1184050114
Name:GRAHAM, ANDREA MARIE (RD,LD)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:MS
Other - First Name:ANDREA
Other - Middle Name:MARIE
Other - Last Name:SHELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD
Mailing Address - Street 1:450 EAST SIGLER AVE.
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:MO
Mailing Address - Zip Code:63555
Mailing Address - Country:US
Mailing Address - Phone:660-465-8511
Mailing Address - Fax:
Practice Address - Street 1:450 E SIGLER AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:MO
Practice Address - Zip Code:63555-1726
Practice Address - Country:US
Practice Address - Phone:660-465-8511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013034940133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4848001OtherMEDICARE PTAN