Provider Demographics
NPI:1528549946
Name:NUNLEY, DESOLA R (LPN)
Entity Type:Individual
Prefix:
First Name:DESOLA
Middle Name:R
Last Name:NUNLEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5057 GRAVOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-2342
Mailing Address - Country:US
Mailing Address - Phone:314-456-8366
Mailing Address - Fax:
Practice Address - Street 1:5057 GRAVOIS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116-2342
Practice Address - Country:US
Practice Address - Phone:314-456-8366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016017207164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse