Healthcare Provider Details

I. General information

NPI: 1356326482
Provider Name (Legal Business Name): CARRIE M WILSON PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL DIV SURG PED, STE 2A
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6022
  • Fax: 866-422-8308
Mailing address:
  • Phone: 314-454-6022
  • Fax: 866-422-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number153626
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: