Healthcare Provider Details

I. General information

NPI: 1417875436
Provider Name (Legal Business Name): KYNDALL AMPY BLACKBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 CUSHMAN ST STE 103
FAIRBANKS AK
99701-4668
US

IV. Provider business mailing address

PO BOX 73189
FAIRBANKS AK
99707-3189
US

V. Phone/Fax

Practice location:
  • Phone: 907-456-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: