Provider Demographics
NPI:1720757198
Name:GRAHAM, KRYSTLE M (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:KRYSTLE
Middle Name:M
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 VOLLMER RD
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2135
Mailing Address - Country:US
Mailing Address - Phone:708-506-9457
Mailing Address - Fax:
Practice Address - Street 1:2320 E 93RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3909
Practice Address - Country:US
Practice Address - Phone:773-967-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-09
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.0236262084N0400X
IL209023626363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty