Healthcare Provider Details

I. General information

NPI: 1669904108
Provider Name (Legal Business Name): EBONY BLACKMON HUMPHREY DNP ARNP PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23205 SE BLACK NUGGET RD APT J2
ISSAQUAH WA
98029-7326
US

IV. Provider business mailing address

400 NW GILMAN BLVD UNIT 2862
ISSAQUAH WA
98027-0258
US

V. Phone/Fax

Practice location:
  • Phone: 206-701-9363
  • Fax:
Mailing address:
  • Phone: 206-701-9363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60929540
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60625891
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN60625891
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN60625891
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: