Healthcare Provider Details

I. General information

NPI: 1942346234
Provider Name (Legal Business Name): CANDI DENISE BLACKWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 US HWY 431
BOAZ AL
35957
US

IV. Provider business mailing address

2454 OAK DR
BOAZ AL
35956-2405
US

V. Phone/Fax

Practice location:
  • Phone: 256-593-8310
  • Fax:
Mailing address:
  • Phone: 256-593-1879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-064377
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: