Healthcare Provider Details

I. General information

NPI: 1780646406
Provider Name (Legal Business Name): ANGELA HOLT BLACKBURN APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12251 S 80TH AVE
PALOS HEIGHTS IL
60463-1290
US

IV. Provider business mailing address

12251 S 80TH AVE
PALOS HEIGHTS IL
60463-1290
US

V. Phone/Fax

Practice location:
  • Phone: 708-923-4000
  • Fax: 708-226-2390
Mailing address:
  • Phone: 708-923-4000
  • Fax: 708-226-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209034971
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number145108
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number145108
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: