Provider Demographics
NPI:1821449679
Name:BLACKBURN, CHARLES DEAN (FNP-BC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DEAN
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials: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:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:314-364-7586
Mailing Address - Fax:
Practice Address - Street 1:1001 CARDWELL ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-1094
Practice Address - Country:US
Practice Address - Phone:636-629-3300
Practice Address - Fax:636-629-7377
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016019132363LF0000X
IN71006846A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily