Healthcare Provider Details

I. General information

NPI: 1679404313
Provider Name (Legal Business Name): MISTY BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 25 RD STE 520
GRAND JUNCTION CO
81505-1303
US

IV. Provider business mailing address

4649 W RD
DE BEQUE CO
81630-9604
US

V. Phone/Fax

Practice location:
  • Phone: 970-654-0511
  • Fax:
Mailing address:
  • Phone: 970-773-1952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: