Provider Demographics
NPI:1447222419
Name:MERRELL, JANET ROSE (MSN, APN, CNS, BC)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:ROSE
Last Name:MERRELL
Suffix:
Gender:F
Credentials:MSN, APN, CNS, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 995860
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-3532
Mailing Address - Country:US
Mailing Address - Phone:636-498-5944
Mailing Address - Fax:618-533-0012
Practice Address - Street 1:904 M L KING DR
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-3532
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:618-533-0012
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004164363LP0808X
IL209.004164364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212772Medicare ID - Type Unspecified