Healthcare Provider Details

I. General information

NPI: 1457224263
Provider Name (Legal Business Name): CASEY CHARLEY BLAIR CHARLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2025
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 GUERNEVILLE RD STE 800
SANTA ROSA CA
95403-7228
US

IV. Provider business mailing address

2448 GUERNEVILLE RD STE 800
SANTA ROSA CA
95403-7228
US

V. Phone/Fax

Practice location:
  • Phone: 707-800-7744
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95041255
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95295810
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: