Healthcare Provider Details

I. General information

NPI: 1790748713
Provider Name (Legal Business Name): KIMBERLY ANN BLACKBURN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 N PARK BLVD BEAUMONT SCHOOL
CLEVELAND HEIGHTS OH
44118-4258
US

IV. Provider business mailing address

11694 PROSPECT RD
STRONGSVILLE OH
44149-2928
US

V. Phone/Fax

Practice location:
  • Phone: 440-223-3292
  • Fax:
Mailing address:
  • Phone: 440-572-0126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-015
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: