Healthcare Provider Details

I. General information

NPI: 1225965726
Provider Name (Legal Business Name): SPENCER MCKINLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2026
Last Update Date: 05/07/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 NASH WAY
SAINT LOUIS MO
63110-1020
US

IV. Provider business mailing address

718 S EUCLID AVE APT 224
SAINT LOUIS MO
63110-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: