Healthcare Provider Details

I. General information

NPI: 1154680288
Provider Name (Legal Business Name): CARLISS RENE GARRETT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4488 FOREST PARK AVE DIV NEUROLOGY ADULT, STE 160
SAINT LOUIS MO
63108-2283
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-1408
  • Fax: 314-747-8427
Mailing address:
  • Phone: 314-362-1408
  • Fax: 314-747-8427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2016015403
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: