Healthcare Provider Details

I. General information

NPI: 1073055901
Provider Name (Legal Business Name): MICHELE DEANN BLAIR APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CLINIC DR # 6
MADISONVILLE KY
42431-1661
US

IV. Provider business mailing address

67 LAKEVIEW DR
PADUCAH KY
42001-5619
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-7246
  • Fax: 270-554-8987
Mailing address:
  • Phone: 270-554-8373
  • Fax: 270-554-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3010855
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number3010855
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: