=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194613943
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES RICHARD FLICKINGER DNP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2025
-----------------------------------------------------
Last Update Date | 06/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 NORTHWESTERN DR STE 1
-----------------------------------------------------
City | STORM LAKE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50588-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-732-5030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 627 S 12TH ST
-----------------------------------------------------
City | SAC CITY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50583-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-430-5422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | A185217
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------