Provider Demographics
NPI:1669238150
Name:EDWARDS, TRISEANA
Entity type:Individual
Prefix:
First Name:TRISEANA
Middle Name:
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14415 BRISTOL AVE
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-4103
Mailing Address - Country:US
Mailing Address - Phone:816-585-7657
Mailing Address - Fax:
Practice Address - Street 1:14415 BRISTOL AVE
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-4103
Practice Address - Country:US
Practice Address - Phone:816-585-7657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20-0298R25246RP1900X
MO20-0298R25172A00000X
174200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174200000XOther Service ProvidersMeals
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No172A00000XOther Service ProvidersDriverGroup - Single Specialty