MEDICARE: MRS. SAMANTHA D'ANN BLACKBURN PMHNP-BC; FNP-C

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	65041	ID
2	163W00000X	Registered Nurse	47259	ID
3	363LA2100X	Acute Care Nurse Practitioner	65041	ID
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	65041	ID

General Provider Information

NPI Number	:	1811534613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SAMANTHA D'ANN BLACKBURN PMHNP-BC; FNP-C

Provider Business Mailing Address
First Line	:	3709 N LOCUST GROVE RD STE 150
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5924
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3709 N LOCUST GROVE RD STE 150
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-5924
Country	:	US
Telephone Number	:	208-208-5430
Fax Number	:

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

Provider Enumeration Date	:	11/29/2019
Last Update Date	:	02/24/2026

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