Healthcare Provider Details

I. General information

NPI: 1053943522
Provider Name (Legal Business Name): SAMANTHA CHARLETTA MCCOY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

IV. Provider business mailing address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-5820
  • Fax: 314-367-7010
Mailing address:
  • Phone: 314-367-5820
  • Fax: 314-367-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2006011721
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: