Healthcare Provider Details

I. General information

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

Provider Other Name: SAMANTHA D'ANN FUNDINGSLAND PMHNP-BC; FNP-C

II. Dates (important events)

Enumeration Date: 11/29/2019
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 N LOCUST GROVE RD STE 150
MERIDIAN ID
83646-5924
US

IV. Provider business mailing address

3709 N LOCUST GROVE RD STE 150
MERIDIAN ID
83646-5924
US

V. Phone/Fax

Practice location:
  • Phone: 208-208-5430
  • Fax: 208-208-5431
Mailing address:
  • Phone: 208-208-5430
  • Fax: 208-208-5431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number65041
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number65041
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number47259
License Number StateID
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number65041
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: