Healthcare Provider Details

I. General information

NPI: 1578075313
Provider Name (Legal Business Name): CARISSA SHANTELL CARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

3632 WATSON RD APT A
SAINT LOUIS MO
63109-1232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6000
  • Fax:
Mailing address:
  • Phone: 314-374-2290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: