Healthcare Provider Details

I. General information

NPI: 1760351944
Provider Name (Legal Business Name): JOHNNIE BLACKBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 EPSEY ALLEN LN
TALLAHASSEE FL
32310-8257
US

IV. Provider business mailing address

3520 EPSEY ALLEN LN
TALLAHASSEE FL
32310-8257
US

V. Phone/Fax

Practice location:
  • Phone: 773-459-9912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11043245
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: