Healthcare Provider Details

I. General information

NPI: 1295991073
Provider Name (Legal Business Name): MAISA A NAZZAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 OLD BALLAS RD STE 104
SAINT LOUIS MO
63141-7083
US

IV. Provider business mailing address

PO BOX 315
BALLWIN MO
63022-0315
US

V. Phone/Fax

Practice location:
  • Phone: 314-993-4949
  • Fax: 314-993-4945
Mailing address:
  • Phone: 419-508-6851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number29008
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036147677
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberE7470
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2016012961
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: