Basic Information
| Provider Information | |||||||||
| NPI: | 1992183511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUTLEDGE | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 505164 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631505164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178202000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 608 OLD ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | SAINT ROBERT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655843730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733365100 | ||||||||
| FaxNumber: | 5733363118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2015 | ||||||||
| LastUpdateDate: | 09/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2015007302 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1992183511 | 05 | MO | MEDICAID |