Healthcare Provider Details

I. General information

NPI: 1205725199
Provider Name (Legal Business Name): CARISSA MARIE REASK CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARISSA MARIE WIDEMAN

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13303 TESSON FERRY RD STE 150
SAINT LOUIS MO
63128-4066
US

IV. Provider business mailing address

PO BOX 419052
SAINT LOUIS MO
63141-9052
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-5239
  • Fax: 314-842-3938
Mailing address:
  • Phone: 314-851-1000
  • Fax: 314-842-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number2025026856
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: