Healthcare Provider Details

I. General information

NPI: 1437062809
Provider Name (Legal Business Name): ANTONISHA DUNCAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 WYOMING ST
SAINT LOUIS MO
63118-2402
US

IV. Provider business mailing address

3725 N ARBOR LAKE DR
EDWARDSVILLE IL
62025-7765
US

V. Phone/Fax

Practice location:
  • Phone: 314-588-7111
  • Fax:
Mailing address:
  • Phone: 314-588-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: