Provider Demographics
NPI:1457458234
Name:MOORE BECKERLE, CARLA (ANP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:MOORE BECKERLE
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:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:314-851-4477
Practice Address - Street 1:637 DUNN RD STE 170
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1759
Practice Address - Country:US
Practice Address - Phone:314-838-5702
Practice Address - Fax:314-839-5596
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017488363L00000X
MO072603363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427553102Medicaid
IL$$$$$$$$$001Medicaid
000081152Medicare PIN
IL$$$$$$$$$001Medicaid
MOP20846Medicare UPIN
MO427553102Medicaid
P20846Medicare UPIN
MO828354740Medicare PIN
MO828352451Medicare PIN