MEDICARE: NICOLE DENISE CARR RN, BSN, MSN, FNP-BC

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	363LF0000X	Family Nurse Practitioner	2019035274	MO

General Provider Information

NPI Number	:	1184244717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE DENISE CARR RN, BSN, MSN, FNP-BC

Provider Business Mailing Address
First Line	:	6915 ROLAND BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-2723
Country	:	US
Telephone Number	:	314-614-4760
Fax Number	:

Provider Business Practice Location Address
First Line	:	3545 LAFAYETTE AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1314
Country	:	US
Telephone Number	:	314-977-9050
Fax Number	:

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

Provider Enumeration Date	:	04/23/2020
Last Update Date	:	04/23/2020

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