MEDICARE: KATRINA BLAKELY RN

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	163W00000X	Registered Nurse	896041	TX

General Provider Information

NPI Number	:	1700396033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA BLAKELY RN

Provider Business Mailing Address
First Line	:	2533 THOMASON CIR APT 170
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006-5020
Country	:	US
Telephone Number	:	817-525-5476
Fax Number	:

Provider Business Practice Location Address
First Line	:	2533 THOMASON CIRCLE APT 170
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006
Country	:	US
Telephone Number	:	817-525-5476
Fax Number	:

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

Provider Enumeration Date	:	09/29/2017
Last Update Date	:	07/21/2022

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