Healthcare Provider Details

I. General information

NPI: 1871162206
Provider Name (Legal Business Name): CHARLES ELDRIDGE III PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 S NATIONAL AVE
SPRINGFIELD MO
65807-7311
US

IV. Provider business mailing address

3600 S NATIONAL AVE
SPRINGFIELD MO
65807-7311
US

V. Phone/Fax

Practice location:
  • Phone: 417-322-6622
  • Fax: 417-350-1935
Mailing address:
  • Phone: 417-322-6622
  • Fax: 417-350-1935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number218639
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2021022694
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: