Healthcare Provider Details

I. General information

NPI: 1285809673
Provider Name (Legal Business Name): NICOLE RENEE GRAHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE RENEE EDMOND M.D.

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 NE INDEPENDENCE AVE
LEES SUMMIT MO
64086-5544
US

IV. Provider business mailing address

901 NE INDEPENDENCE AVE
LEES SUMMIT MO
64086-5544
US

V. Phone/Fax

Practice location:
  • Phone: 816-347-3223
  • Fax:
Mailing address:
  • Phone: 816-347-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01-52448
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberTRN15706
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME111414
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2016033090
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: