Healthcare Provider Details

I. General information

NPI: 1417594102
Provider Name (Legal Business Name): MRS. REBECCA J BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2019
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MUELLER BLVD
AUSTIN TX
78723-3079
US

IV. Provider business mailing address

3746 BAINBRIDGE ST
ROUND ROCK TX
78681-2472
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberAP144164
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: