Provider Demographics
NPI:1710902176
Name:CARLL, VICKIE JOANN (ANP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:JOANN
Last Name:CARLL
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12125 WOODCREST EXECUTIVE DR
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-5001
Mailing Address - Country:US
Mailing Address - Phone:314-317-0600
Mailing Address - Fax:314-317-0606
Practice Address - Street 1:6420 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1811
Practice Address - Country:US
Practice Address - Phone:314-317-0600
Practice Address - Fax:314-317-0606
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109547363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1710902176Medicaid
P22478Medicare UPIN