Healthcare Provider Details

I. General information

NPI: 1417330531
Provider Name (Legal Business Name): REYANNA G MASSAQUOI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

IV. Provider business mailing address

1438 S GRAND BLVD
SAINT LOUIS MO
63104-1027
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6082
  • Fax: 314-977-6086
Mailing address:
  • Phone: 314-977-6082
  • Fax: 314-977-6086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2015017198
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number67580
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: