Healthcare Provider Details

I. General information

NPI: 1346960051
Provider Name (Legal Business Name): NICHOLE MARIE RENN EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 S TAYLOR AVE
SAINT LOUIS MO
63110-1567
US

IV. Provider business mailing address

825 S TAYLOR AVE
SAINT LOUIS MO
63110-1567
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-0132
  • Fax:
Mailing address:
  • Phone: 314-977-0132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: