Healthcare Provider Details

I. General information

NPI: 1811534613
Provider Name (Legal Business Name): SAMANTHA D'ANN BLACKBURN AGACNP - BC; FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. SAMANTHA D'ANN FUNDINGSLAND

II. Dates (important events)

Enumeration Date: 11/29/2019
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 N WHITLEY DR
FRUITLAND ID
83619-2437
US

IV. Provider business mailing address

808 N WHITLEY DR
FRUITLAND ID
83619-2437
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-2672
  • Fax:
Mailing address:
  • Phone: 208-452-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number47259
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number65041
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number65041
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: