Basic Information
| Provider Information | |||||||||
| NPI: | 1952645087 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANK | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | CNM, APRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6420 CLAYTON RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171811 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1031 BELLEVUE AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149777455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 02/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WL0100X | 11132674 | MO | N | Nursing Service Providers | Registered Nurse | Lactation Consultant | 367A00000X | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 2015026430 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 2015026430 | 01 | MO | STATE BOARD OF NURSING | OTHER |