Healthcare Provider Details

I. General information

NPI: 1497194740
Provider Name (Legal Business Name): ALLIE BLACKWELL RN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9816
US

IV. Provider business mailing address

97 GREAT TEAYS BLVD STE 6
SCOTT DEPOT WV
25560-9816
US

V. Phone/Fax

Practice location:
  • Phone: 304-757-6999
  • Fax: 304-201-5019
Mailing address:
  • Phone: 304-757-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17693
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: