Provider Demographics
NPI:1134265556
Name:CARLTON, JEANNIE M (FNP)
Entity type:Individual
Prefix:
First Name:JEANNIE
Middle Name:M
Last Name:CARLTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 PASSOVER RD
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-2834
Mailing Address - Country:US
Mailing Address - Phone:573-723-5157
Mailing Address - Fax:573-693-1680
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:SUITE 102
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-348-8045
Practice Address - Fax:573-348-8046
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO111554363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1134265556Medicaid
MO431560263OtherTRICARE
MO500023720OtherRR MCR
MOP55033Medicare UPIN
MO1134265556Medicaid
MO000081244Medicare PIN