Provider Demographics
NPI:1649782269
Name:CARLSON, ELLEN CLAIRE (AGNP)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:CLAIRE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 S NEW BALLAS RD STE 2015
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8253
Mailing Address - Country:US
Mailing Address - Phone:314-251-1700
Mailing Address - Fax:
Practice Address - Street 1:625 S NEW BALLAS RD STE 2015
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8253
Practice Address - Country:US
Practice Address - Phone:314-251-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-05
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017038788363LG0600X
MOAG10170148363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420049783Medicaid