Healthcare Provider Details

I. General information

NPI: 1609857572
Provider Name (Legal Business Name): NICOLE P BLACKWOOD CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 CHICAGO AVE MAIL ROUTE 10735
MINNEAPOLIS MN
55407-1321
US

IV. Provider business mailing address

2925 CHICAGO AVE MAIL ROUTE 10735
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 612-262-7800
  • Fax: 612-262-7022
Mailing address:
  • Phone: 612-262-7800
  • Fax: 612-262-7022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number7298
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: