Healthcare Provider Details

I. General information

NPI: 1619343274
Provider Name (Legal Business Name): CHARISSA FAITH HOLESKO ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2015
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SAINT ELIZABETH BLVD
O FALLON IL
62269-1281
US

IV. Provider business mailing address

3 SAINT ELIZABETH BLVD
O FALLON IL
62269-1281
US

V. Phone/Fax

Practice location:
  • Phone: 618-641-5803
  • Fax: 618-607-5116
Mailing address:
  • Phone: 618-641-5803
  • Fax: 618-607-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209035756
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2015038009
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: