MEDICARE: CARRIE JO JOHANNS AGACNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	2012011626	MO

General Provider Information

NPI Number	:	1366199614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE JO JOHANNS AGACNP

Provider Business Mailing Address
First Line	:	19 MILLBROOK LN
Second Line	:
City	:	KIRKWOOD
State	:	MO
Zip	:	63122-5202
Country	:	US
Telephone Number	:	763-227-8527
Fax Number	:

Provider Business Practice Location Address
First Line	:	232 S WOODS MILL RD
Second Line	:
City	:	CHESTERFIELD
State	:	MO
Zip	:	63017-3485
Country	:	US
Telephone Number	:	314-434-1500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2022
Last Update Date	:	03/07/2022

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