Provider Demographics
NPI:1154680288
Name:GARRETT, CARLISS RENE (ANP)
Entity type:Individual
Prefix:MS
First Name:CARLISS
Middle Name:RENE
Last Name:GARRETT
Suffix:
Gender:
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-1408
Mailing Address - Fax:314-747-8427
Practice Address - Street 1:4488 FOREST PARK AVE
Practice Address - Street 2:DIV NEUROLOGY ADULT, STE 160
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2283
Practice Address - Country:US
Practice Address - Phone:314-362-1408
Practice Address - Fax:314-747-8427
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016015403363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429636103Medicaid
MO1154680288Medicaid