MEDICARE: STEVIE BLACKBURN-LAZALDE

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1770442352
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVIE BLACKBURN-LAZALDE

Provider Business Mailing Address
First Line	:	3008 NANCY MCDONALD DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79936-3364
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14100 6 MILE CYPRESS PKWY
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33912-4314
Country	:	US
Telephone Number	:	239-533-7695
Fax Number	:

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

Provider Enumeration Date	:	01/19/2026
Last Update Date	:	01/19/2026

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