Provider Demographics
NPI:1649243619
Name:GRAHAM, JULIE A (PMHNP)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 W AGENCY RD
Mailing Address - Street 2:
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1667
Mailing Address - Country:US
Mailing Address - Phone:319-768-5858
Mailing Address - Fax:319-752-4653
Practice Address - Street 1:400 N 17TH ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3452
Practice Address - Country:US
Practice Address - Phone:319-524-5734
Practice Address - Fax:319-524-5758
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO142186363LF0000X
IAG095717363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429098114Medicaid
821442751Medicare ID - Type Unspecified
MO429098114Medicaid