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General NPI Number Information
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NPI Number | 1669904108
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Entity Type | Individual
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Provider Name | EBONY BLACKMON HUMPHREY DNP ARNP PMHNP-BC
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Gender | Female
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Dates
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Enumeration Date | 04/03/2017
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Last Update Date | 08/10/2026
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Provider Practice Location Address
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Address Line | 23205 SE BLACK NUGGET RD APT J2
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City | ISSAQUAH
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State | WA
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Zip | 98029-7326
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Country | US
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Telephone | 206-701-9363
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Fax |
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Provider Business Mailing Address
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Address Line | 400 NW GILMAN BLVD UNIT 2862
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City | ISSAQUAH
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State | WA
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Zip | 98027-0258
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Country | US
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Telephone | 206-701-9363
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | AP60929540
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN60625891
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 163WC0400X
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Taxonomy Name | Case Management Registered Nurse
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License Number | RN60625891
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License Number State | WA
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Taxonomy #4
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | RN60625891
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License Number State | WA
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