=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497905590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH A BLACKWELL MSN, RN, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2008
-----------------------------------------------------
Last Update Date | 03/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 JEFFERSON BARRACKS RD
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63125-4181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-652-4100
-----------------------------------------------------
Fax | 314-894-6594
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 BIRCHLAWN DR
-----------------------------------------------------
City | FLORISSANT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63033-6333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-607-8777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 123558
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 123558
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WD1100X
-----------------------------------------------------
Taxonomy Name | Peritoneal Dialysis Registered Nurse
-----------------------------------------------------
License Number | 123558
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 163WN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Registered Nurse
-----------------------------------------------------
License Number | 123558
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 123558
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------