Healthcare Provider Details

I. General information

NPI: 1386562825
Provider Name (Legal Business Name): LEEANNA BLACKBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 EXECUTIVE PARK S
ATLANTA GA
30329-2288
US

IV. Provider business mailing address

7 EXECUTIVE PARK DR NE APT 1301
ATLANTA GA
30329-2263
US

V. Phone/Fax

Practice location:
  • Phone: 423-754-7586
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: