Healthcare Provider Details

I. General information

NPI: 1821861840
Provider Name (Legal Business Name): MAURICE ELLIS BLACKBIRD DNP, APRN, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BLUFF ST
WINNEBAGO NE
68071-9703
US

IV. Provider business mailing address

PO BOX 213
ROSALIE NE
68055-0213
US

V. Phone/Fax

Practice location:
  • Phone: 402-745-3950
  • Fax: 402-243-1310
Mailing address:
  • Phone: 712-635-5459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number114952
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: