Healthcare Provider Details

I. General information

NPI: 1093527632
Provider Name (Legal Business Name): KRISTINA GRAHAM APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 RENAISSANCE DR STE C
LAS VEGAS NV
89119-6751
US

IV. Provider business mailing address

10628 TRUSSELL ST
LAS VEGAS NV
89141-4263
US

V. Phone/Fax

Practice location:
  • Phone: 702-901-4880
  • Fax: 702-434-3530
Mailing address:
  • Phone: 702-292-6054
  • Fax: 702-434-3530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number866768
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: