=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366052771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHANIE ELIZABETH BLACKMORE FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2020
-----------------------------------------------------
Last Update Date | 10/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14961 W BELL RD STE 100
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-439-5176
-----------------------------------------------------
Fax | 855-583-1420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14961 W BELL RD STE 100
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-439-5176
-----------------------------------------------------
Fax | 623-304-1804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 245687
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 245687
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------