Healthcare Provider Details

I. General information

NPI: 1750612669
Provider Name (Legal Business Name): CHARLES NEWTON MULLICAN ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2010
Last Update Date: 04/17/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S KINGSHIGHWAY BLVD DEPT EMERGENCY MED
SAINT LOUIS MO
63110-1014
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-9123
  • Fax: 314-747-3338
Mailing address:
  • Phone: 314-362-9123
  • Fax: 314-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2010010952
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: