Provider Demographics
NPI:1750612669
Name:MULLICAN, CHARLES NEWTON (ACNP)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:NEWTON
Last Name:MULLICAN
Suffix:
Gender:
Credentials:ACNP
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-362-9123
Mailing Address - Fax:314-747-3338
Practice Address - Street 1:400 S KINGSHIGHWAY BLVD
Practice Address - Street 2:DEPT EMERGENCY MED
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1014
Practice Address - Country:US
Practice Address - Phone:314-362-9123
Practice Address - Fax:314-747-3338
Is Sole Proprietor?:No
Enumeration Date:2010-01-18
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2010010952363LA2100X
MO2004030371163W00000X
MO20100010952363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO424152601Medicaid
MO1750612669Medicaid