MEDICARE: TAKIA NUNNELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246QL0900X	Laboratory Management Specialist/Technologist	5387696376TN	MO

General Provider Information

NPI Number	:	1629914387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAKIA NUNNELLY

Provider Business Mailing Address
First Line	:	1927 S COMPTON AVE APT 3
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1579
Country	:	US
Telephone Number	:	314-532-7975
Fax Number	:

Provider Business Practice Location Address
First Line	:	1927 S COMPTON AVE APT 3
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1579
Country	:	US
Telephone Number	:	314-532-7975
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2026
Last Update Date	:	04/27/2026

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Directions to “ TAKIA NUNNELLY ” Practice Location

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