MEDICARE: MISTY BLACKWELL

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	172A00000X	Driver		CO

General Provider Information

NPI Number	:	1679404313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISTY BLACKWELL

Provider Business Mailing Address
First Line	:	4649 W RD
Second Line	:
City	:	DE BEQUE
State	:	CO
Zip	:	81630-9604
Country	:	US
Telephone Number	:	970-773-1952
Fax Number	:

Provider Business Practice Location Address
First Line	:	571 25 RD STE 520
Second Line	:
City	:	GRAND JUNCTION
State	:	CO
Zip	:	81505-1303
Country	:	US
Telephone Number	:	970-654-0511
Fax Number	:

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

Provider Enumeration Date	:	05/28/2026
Last Update Date	:	05/28/2026

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Directions to “ MISTY BLACKWELL ” Practice Location

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