Provider Demographics
NPI:1598782013
Name:MASSMANN, CAROL V (CPNP)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:V
Last Name:MASSMANN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-454-6162
Mailing Address - Fax:314-454-2174
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:STE 35
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6162
Practice Address - Fax:314-454-2174
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113735363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid