Healthcare Provider Details

I. General information

NPI: 1629914387
Provider Name (Legal Business Name): TAKIA NUNNELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1927 S COMPTON AVE APT 3
SAINT LOUIS MO
63104-1579
US

IV. Provider business mailing address

1927 S COMPTON AVE APT 3
SAINT LOUIS MO
63104-1579
US

V. Phone/Fax

Practice location:
  • Phone: 314-532-7975
  • Fax:
Mailing address:
  • Phone: 314-532-7975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number5387696376TN
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: