Provider Demographics
NPI:1053197525
Name:GRAHAM, KAILYN MARIE (FNP, RN)
Entity type:Individual
Prefix:
First Name:KAILYN
Middle Name:MARIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:FNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:636-735-4122
Mailing Address - Fax:636-735-4123
Practice Address - Street 1:17701 EDISON AVE STE 101
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1266
Practice Address - Country:US
Practice Address - Phone:636-735-4122
Practice Address - Fax:636-735-4123
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2023007989363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily