Healthcare Provider Details

I. General information

NPI: 1457714487
Provider Name (Legal Business Name): CAROLYN MARIE MCGINNIS AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 SOUTHSIDE AVE
WEBSTER GROVES MO
63119-4851
US

IV. Provider business mailing address

419 SOUTHSIDE AVE
WEBSTER GROVES MO
63119-4851
US

V. Phone/Fax

Practice location:
  • Phone: 314-302-1126
  • Fax:
Mailing address:
  • Phone: 314-302-1126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200901974
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2016000695
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: