Provider Demographics
NPI:1356725345
Name:GRAHAM, HILLARIE (FNP-BC)
Entity type:Individual
Prefix:
First Name:HILLARIE
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:HILLARIE
Other - Middle Name:
Other - Last Name:HALBROOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:1032 CROSSWINDS CT
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4836
Practice Address - Country:US
Practice Address - Phone:636-332-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1356725345Medicaid
MO1356725345Medicaid