MEDICARE: MRS. CAROLINE BLAKE ELLENBURG YOUNGBLOOD CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	15875	TN
2	363LF0000X	Family Nurse Practitioner	1-120527	AL

General Provider Information

NPI Number	:	1619242674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROLINE BLAKE ELLENBURG YOUNGBLOOD CRNP

Provider Business Mailing Address
First Line	:	504 BROOKWOOD BLVD
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-6802
Country	:	US
Telephone Number	:	205-871-9661
Fax Number	:	205-870-1621

Provider Business Practice Location Address
First Line	:	504 BROOKWOOD BLVD
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35209-6802
Country	:	US
Telephone Number	:	205-871-9661
Fax Number	:	205-870-1621

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2012
Last Update Date	:	03/23/2015

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