Healthcare Provider Details

I. General information

NPI: 1184244717
Provider Name (Legal Business Name): NICOLE DENISE CARR RN, BSN, MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 LAFAYETTE AVE
SAINT LOUIS MO
63104-1314
US

IV. Provider business mailing address

6915 ROLAND BLVD
SAINT LOUIS MO
63121-2723
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-9050
  • Fax:
Mailing address:
  • Phone: 314-614-4760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2019035274
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: