Healthcare Provider Details

I. General information

NPI: 1033936620
Provider Name (Legal Business Name): CASSANDRA BLACKBURN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4035 W ALAMEDA RD
GLENDALE AZ
85310-3304
US

IV. Provider business mailing address

20402 N 15TH AVE
PHOENIX AZ
85027-3699
US

V. Phone/Fax

Practice location:
  • Phone: 623-445-4700
  • Fax:
Mailing address:
  • Phone: 623-445-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number240033
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: