Basic Information
| Provider Information | |||||||||
| NPI: | 1134265556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLTON | ||||||||
| FirstName: | JEANNIE | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 PASSOVER RD | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650652834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737235157 | ||||||||
| FaxNumber: | 5736931680 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650653050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733488045 | ||||||||
| FaxNumber: | 5733488046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 111554 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1134265556 | 05 | MO | MEDICAID | 431560263 | 01 | MO | TRICARE | OTHER | 500023720 | 01 | MO | RR MCR | OTHER |