Provider Demographics
NPI:1104092865
Name:PLISCO, CARRIE LEE (WHNP, AGPCNP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LEE
Last Name:PLISCO
Suffix:
Gender:F
Credentials:WHNP, AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-839-4554
Mailing Address - Fax:314-837-0047
Practice Address - Street 1:253 DUNN RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-7928
Practice Address - Country:US
Practice Address - Phone:314-839-4554
Practice Address - Fax:314-837-0047
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020014169363LG0600X
MO1999140477363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology