Healthcare Provider Details

I. General information

NPI: 1083166433
Provider Name (Legal Business Name): TRACEY ANN CARPENTER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACEY ANN BROADWATER RN

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S WOODS MILL RD STE 400
CHESTERFIELD MO
63017-3467
US

IV. Provider business mailing address

622 DARTMOUTH CREST DR
WILDWOOD MO
63011-5433
US

V. Phone/Fax

Practice location:
  • Phone: 314-878-2888
  • Fax: 314-576-8167
Mailing address:
  • Phone: 636-284-0263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2016023933
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016023933
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: