Provider Demographics
NPI:1467275487
Name:PHELAN, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:PHELAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 S NEW BALLAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8221
Mailing Address - Country:US
Mailing Address - Phone:844-735-4710
Mailing Address - Fax:636-237-4074
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015045012163W00000X
MO2024049964363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse