Provider Demographics
NPI:1134374309
Name:PURDY, CHARLES ROBERT JR (RN)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ROBERT
Last Name:PURDY
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5667 MARK TRL
Mailing Address - Street 2:
Mailing Address - City:HOUSE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:63051-2240
Mailing Address - Country:US
Mailing Address - Phone:727-776-5948
Mailing Address - Fax:
Practice Address - Street 1:5667 MARK TRL
Practice Address - Street 2:
Practice Address - City:HOUSE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:63051-2240
Practice Address - Country:US
Practice Address - Phone:727-776-5948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR51609163W00000X
FLRN9245172163W00000X
CA635760163W00000X
MO2003026652163W00000X
KY1104666163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse