Healthcare Provider Details

I. General information

NPI: 1700857216
Provider Name (Legal Business Name): SALLY BLACKBURN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY PENNINGS

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 EUCLID AVE SUITE 6
BRISTOL VA
24201-3655
US

IV. Provider business mailing address

PO BOX 729
SALTVILLE VA
24370-0729
US

V. Phone/Fax

Practice location:
  • Phone: 276-669-5179
  • Fax: 276-466-8870
Mailing address:
  • Phone: 276-496-4492
  • Fax: 276-496-4839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024164957
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: