Healthcare Provider Details

I. General information

NPI: 1821398397
Provider Name (Legal Business Name): WYVON BLACKWELL MSN, APRN,FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 W 155TH ST
HARVEY IL
60426
US

IV. Provider business mailing address

31 W 155TH ST
HARVEY IL
60426-3556
US

V. Phone/Fax

Practice location:
  • Phone: 708-596-5177
  • Fax: 708-596-5518
Mailing address:
  • Phone: 708-596-5177
  • Fax: 708-596-5518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number28180607A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0214515
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number309007962
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209011447
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: