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NPI Code Detail

MEDICARE: MISTY BLACKBURN NP

MEDICARE: MISTY BLACKBURN NP
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
1363LF0000XFamily Nurse Practitioner71009109AIN

General Provider Information

NPI Number : 1770137044
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISTY BLACKBURN NP
Provider Business Mailing Address
First Line : PO BOX 775383
Second Line :
City : CHICAGO
State : IL
Zip : 60677-5383
Country : US
Telephone Number : 812-376-5315
Fax Number :
Provider Business Practice Location Address
First Line : 3015 10TH ST STE A
Second Line :
City : COLUMBUS
State : IN
Zip : 47201-7091
Country : US
Telephone Number : 812-372-8883
Fax Number : 812-373-3265
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/25/2019
Last Update Date : 03/26/2026

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