Provider Demographics
NPI:1184739609
Name:CARTER-SIMMONS, BERTHA Y (APN)
Entity type:Individual
Prefix:MRS
First Name:BERTHA
Middle Name:Y
Last Name:CARTER-SIMMONS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S MERAMEC AVE
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-1711
Mailing Address - Country:US
Mailing Address - Phone:314-615-8153
Mailing Address - Fax:314-615-8303
Practice Address - Street 1:111 S MERAMEC AVE
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-1711
Practice Address - Country:US
Practice Address - Phone:314-615-8153
Practice Address - Fax:314-615-8303
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO052258363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423989417Medicaid
MOP00213367OtherMEDICARE RAILROAD
MO423989417Medicaid
MO000081116Medicare ID - Type Unspecified