MEDICARE: DEBORRAH BLACKBURN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1710828322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORRAH BLACKBURN

Provider Business Mailing Address
First Line	:	12680 OLIVE BLVD STE 300
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-6322
Country	:	US
Telephone Number	:	314-251-8888
Fax Number	:

Provider Business Practice Location Address
First Line	:	12680 OLIVE BLVD STE 300
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-6322
Country	:	US
Telephone Number	:	314-251-8888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2026
Last Update Date	:	04/06/2026

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Directions to “ DEBORRAH BLACKBURN ” Practice Location

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