Healthcare Provider Details

I. General information

NPI: 1710807664
Provider Name (Legal Business Name): BLACKHAWK MEDICAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 AULENBROCK DR # 100-B
CANTON MS
39046-7061
US

IV. Provider business mailing address

115 AULENBROCK DR # 100-B
CANTON MS
39046-7061
US

V. Phone/Fax

Practice location:
  • Phone: 601-624-1082
  • Fax:
Mailing address:
  • Phone: 601-624-1082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: VIRGINIA LEA POWELL
Title or Position: OWNER, NURSE PRACTITIONER
Credential: A-GPCNP
Phone: 601-624-1082