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General NPI Number Information
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NPI Number | 1831526557
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Entity Type | Individual
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Provider Name | TARA RENE BLACKWELDER NP-C
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Gender | Female
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Dates
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Enumeration Date | 09/27/2013
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Last Update Date | 12/11/2025
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Provider Practice Location Address
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Address Line | 224 W D. L. INGRAM AVENUE, BLDG. 1408
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City | CANNON AFB
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State | NM
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Zip | 88103-5014
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Country | US
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Telephone | 575-784-2778
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Fax |
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Provider Business Mailing Address
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Address Line | 27TH SPECIAL OPERATIONS MEDICAL GROUP 224 W D. L. INGRAM AVENUE, BLDG. 1408
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City | CANNON AFB
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State | NM
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Zip | 88103-5014
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Country | US
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Telephone | 575-784-2778
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 115187
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License Number State | NE
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