Provider Demographics
NPI:1184244717
Name:CARR, NICOLE DENISE (RN, BSN, MSN, FNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:CARR
Suffix:
Gender:F
Credentials:RN, BSN, MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 ROLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-2723
Mailing Address - Country:US
Mailing Address - Phone:314-614-4760
Mailing Address - Fax:
Practice Address - Street 1:3545 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1314
Practice Address - Country:US
Practice Address - Phone:314-977-9050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019035274363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty