Healthcare Provider Details

I. General information

NPI: 1750445219
Provider Name (Legal Business Name): REBECCA ANN BLACKBURN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 S LAFOUNTAIN ST
KOKOMO IN
46902-3803
US

IV. Provider business mailing address

3500 S LAFOUNTAIN ST P.O. BOX 9011
KOKOMO IN
46902-3803
US

V. Phone/Fax

Practice location:
  • Phone: 765-453-8352
  • Fax: 765-453-8457
Mailing address:
  • Phone: 765-453-8352
  • Fax: 765-453-8457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37001345A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: