Provider Demographics
NPI:1710755095
Name:MINOR, TIMIRA NACOLE
Entity Type:Individual
Prefix:MS
First Name:TIMIRA
Middle Name:NACOLE
Last Name:MINOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63133-1211
Mailing Address - Country:US
Mailing Address - Phone:314-585-2040
Mailing Address - Fax:
Practice Address - Street 1:4480 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1624
Practice Address - Country:US
Practice Address - Phone:314-273-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor