Healthcare Provider Details

I. General information

NPI: 1194662189
Provider Name (Legal Business Name): STEPHANIE LYNN BLACKMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE LYNN HOWARD

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 GROVE ST
MASSENA NY
13662-2615
US

IV. Provider business mailing address

480 COUNTY ROUTE 4
OGDENSBURG NY
13669-5324
US

V. Phone/Fax

Practice location:
  • Phone: 315-769-2494
  • Fax:
Mailing address:
  • Phone: 315-769-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF04260402
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: