Provider Demographics
NPI:1336997691
Name:CARLYLE, ADDIE ELIZABETH
Entity Type:Individual
Prefix:
First Name:ADDIE
Middle Name:ELIZABETH
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7972 STATE HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:ORAN
Mailing Address - State:MO
Mailing Address - Zip Code:63771-9184
Mailing Address - Country:US
Mailing Address - Phone:573-986-8951
Mailing Address - Fax:
Practice Address - Street 1:3095 LEXINGTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2629
Practice Address - Country:US
Practice Address - Phone:573-987-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-10
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023026241363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily