Healthcare Provider Details

I. General information

NPI: 1184128514
Provider Name (Legal Business Name): MRS. CHRISTY P BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTY P BLACKWELL FNP-BC, APRN

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4104 BUFFALO TRL
EVANS GA
30809-0959
US

IV. Provider business mailing address

4104 BUFFALO TRL
EVANS GA
30809-0959
US

V. Phone/Fax

Practice location:
  • Phone: 706-294-6135
  • Fax: 706-294-6135
Mailing address:
  • Phone: 706-294-6135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN170034
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP170034
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN170034
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: