MEDICARE: ANNIE BLYSTONE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	10001248	OR
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	APRN11039470	FL

General Provider Information

NPI Number	:	1104617513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNIE BLYSTONE

Provider Business Mailing Address
First Line	:	PO BOX 4228
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-4228
Country	:	US
Telephone Number	:	541-617-5369
Fax Number	:	541-323-3866

Provider Business Practice Location Address
First Line	:	7425 N UNIVERSITY DR
Second Line	:
City	:	TAMARAC
State	:	FL
Zip	:	33321-2901
Country	:	US
Telephone Number	:	954-247-4627
Fax Number	:	603-461-3545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2025
Last Update Date	:	05/20/2026

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Directions to “ ANNIE BLYSTONE ” Practice Location

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