Provider Demographics
NPI:1700415130
Name:BLICKENSTAFF, HEATHER (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BLICKENSTAFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:SCHULJAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:WUSM PEDS, 1 CHILDRENS PL CB8116
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110
Mailing Address - Country:US
Mailing Address - Phone:314-454-2527
Mailing Address - Fax:314-747-8880
Practice Address - Street 1:WUSM PEDS, 1 CHILDRENS PL CB8116
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110
Practice Address - Country:US
Practice Address - Phone:314-454-2527
Practice Address - Fax:314-747-8880
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2023010994208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program