Provider Demographics
NPI:1154680288
Name:GARRETT, CARLISS RENE (ANP)
Entity Type:Individual
Prefix:MS
First Name:CARLISS
Middle Name:RENE
Last Name:GARRETT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8111
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-747-8427
Practice Address - Street 1:4488 FOREST PARK AVE
Practice Address - Street 2:DIV NEUROLOGY ADULT, STE 160
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2283
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-747-8427
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016015403363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429636103Medicaid
MO1154680288Medicaid