Healthcare Provider Details

I. General information

NPI: 1679481998
Provider Name (Legal Business Name): VELICIA JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4132 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63113-2730
US

IV. Provider business mailing address

4132 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63113-2730
US

V. Phone/Fax

Practice location:
  • Phone: 314-406-9048
  • Fax:
Mailing address:
  • Phone: 314-406-9048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: