Healthcare Provider Details

I. General information

NPI: 1083694087
Provider Name (Legal Business Name): NICOLE M BURKEMPER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 05/27/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S GRAND BLVD FL 3
SAINT LOUIS MO
63104-1016
US

IV. Provider business mailing address

1008 S SPRING AVE FL 3
SAINT LOUIS MO
63110-2520
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-3400
  • Fax: 314-977-7613
Mailing address:
  • Phone: 314-977-1771
  • Fax: 317-977-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number44829
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2006009409
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: