Healthcare Provider Details

I. General information

NPI: 1821449679
Provider Name (Legal Business Name): CHARLES DEAN BLACKBURN FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CARDWELL ST
SAINT CLAIR MO
63077-1094
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 636-629-3300
  • Fax: 636-629-7377
Mailing address:
  • Phone: 314-364-7586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016019132
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71006846A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: