Healthcare Provider Details

I. General information

NPI: 1053173716
Provider Name (Legal Business Name): BLAKELY ADAMS MCCALISTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WALNUT ST
OWENSBORO KY
42301-2956
US

IV. Provider business mailing address

430 BOOTH AVE
OWENSBORO KY
42301-5031
US

V. Phone/Fax

Practice location:
  • Phone: 270-689-6879
  • Fax:
Mailing address:
  • Phone: 270-903-5190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4063372
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1178445
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: