Provider Demographics
NPI:1780925396
Name:GRAHAM, BRANDY NICHOLE (FNP)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:NICHOLE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:NICHOLE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:851 HIGHWAY 287 N
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2664
Mailing Address - Country:US
Mailing Address - Phone:817-842-2500
Mailing Address - Fax:817-842-2599
Practice Address - Street 1:6363 N STATE HIGHWAY 161 STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2239
Practice Address - Country:US
Practice Address - Phone:469-200-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX735423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX322921301Medicaid
TX322921301Medicaid