MEDICARE: CHERYL ANN BLACKWELL C.R.N.A.

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	367500000X	Certified Registered Nurse Anesthetist	28171006A	IN
2	367500000X	Certified Registered Nurse Anesthetist	ARNP9224474	FL
3	367500000X	Certified Registered Nurse Anesthetist		IL

General Provider Information

NPI Number	:	1659583037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL ANN BLACKWELL C.R.N.A.

Provider Business Mailing Address
First Line	:	339 W BARRY AVE
Second Line	:	6B
City	:	CHICAGO
State	:	IL
Zip	:	60657-5653
Country	:	US
Telephone Number	:	773-296-4091
Fax Number	:

Provider Business Practice Location Address
First Line	:	339 W BARRY AVE
Second Line	:	6B
City	:	CHICAGO
State	:	IL
Zip	:	60657-5653
Country	:	US
Telephone Number	:	773-296-4091
Fax Number	:

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

Provider Enumeration Date	:	05/05/2007
Last Update Date	:	07/08/2007

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