Healthcare Provider Details

I. General information

NPI: 1114253549
Provider Name (Legal Business Name): LYNN ASHLEY CUNNINGHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 W PINE CT
SAINT LOUIS MO
63108-2110
US

IV. Provider business mailing address

4579 LACLEDE AVE # 443
SAINT LOUIS MO
63108-2103
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-0403
  • Fax: 314-367-0178
Mailing address:
  • Phone: 314-367-0403
  • Fax: 314-367-0178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number2004017382
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: