Healthcare Provider Details

I. General information

NPI: 1639012297
Provider Name (Legal Business Name): KAZUNA NAKAMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANNY LIN MD

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 E 2ND ST
O FALLON IL
62269-2134
US

IV. Provider business mailing address

414 E 2ND ST
O FALLON IL
62269-2134
US

V. Phone/Fax

Practice location:
  • Phone: 224-220-7291
  • Fax:
Mailing address:
  • Phone: 224-220-7291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number1386059277
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: