Healthcare Provider Details

I. General information

NPI: 1790934032
Provider Name (Legal Business Name): MISS ANNETTA SYKES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 EDMAR LN
SAINT LOUIS MO
63138-1714
US

IV. Provider business mailing address

1700 EDMAR LN
SAINT LOUIS MO
63138-1714
US

V. Phone/Fax

Practice location:
  • Phone: 314-614-7062
  • Fax: 314-473-1094
Mailing address:
  • Phone: 314-614-7062
  • Fax: 314-473-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number2008010317
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: