Healthcare Provider Details

I. General information

NPI: 1629902770
Provider Name (Legal Business Name): NASIRA QUEEN ISSAKA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11358 RANGER DR
SAINT LOUIS MO
63128-1414
US

IV. Provider business mailing address

11358 RANGER DR
SAINT LOUIS MO
63128-1414
US

V. Phone/Fax

Practice location:
  • Phone: 978-696-6998
  • Fax:
Mailing address:
  • Phone: 978-696-6998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2026024580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: