Provider Demographics
NPI:1043568280
Name:BLACKBURN, DENISE P (APRN, FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:P
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 MARTINA DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-5213
Mailing Address - Country:US
Mailing Address - Phone:636-259-0207
Mailing Address - Fax:
Practice Address - Street 1:1011 BOWLES AVE
Practice Address - Street 2:SUITE G10
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2395
Practice Address - Country:US
Practice Address - Phone:314-965-9980
Practice Address - Fax:314-965-1127
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO125820163W00000X
MO2012021023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse