Healthcare Provider Details

I. General information

NPI: 1811235328
Provider Name (Legal Business Name): ANN ELIZABETH BLACKWELL R.N,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 W SAN JUAN DR
BLOOMINGTON IN
47403-4385
US

IV. Provider business mailing address

505 W SAN JUAN DR APT/SUITE
BLOOMINGTON IN
47403-4385
US

V. Phone/Fax

Practice location:
  • Phone: 812-320-1852
  • Fax:
Mailing address:
  • Phone: 812-320-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number28158668A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: