MEDICARE: KATHERINE LINDSEY BLALOCK ACNP

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	363LA2100X	Acute Care Nurse Practitioner	1003334	TX
2	363L00000X	Nurse Practitioner	1003334	TX
3	363LG0600X	Gerontology Nurse Practitioner	1003334	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1003334	OTHER	TX	NURSE PRACTITIONER LICENSE
2	831405	OTHER	TX	RN LICENSE

General Provider Information

NPI Number	:	1639771330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHERINE LINDSEY BLALOCK ACNP

Provider Business Mailing Address
First Line	:	1201 FAIRMOUNT AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4215
Country	:	US
Telephone Number	:	817-335-5288
Fax Number	:	817-338-0927

Provider Business Practice Location Address
First Line	:	6100 HARRIS PKWY STE 285
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4127
Country	:	US
Telephone Number	:	817-263-5864
Fax Number	:	817-394-3994

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

Provider Enumeration Date	:	11/09/2020
Last Update Date	:	01/19/2026

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