Healthcare Provider Details

I. General information

NPI: 1891164349
Provider Name (Legal Business Name): BLAIR BROCKMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 KENTUCKY AVE SUITE 301
PADUCAH KY
42003-3817
US

IV. Provider business mailing address

2605 KENTUCKY AVE SUITE 306
PADUCAH KY
42003-3800
US

V. Phone/Fax

Practice location:
  • Phone: 270-575-3113
  • Fax: 270-575-3135
Mailing address:
  • Phone: 270-415-7653
  • Fax: 270-575-8359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009743
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: