MEDICARE: LAUREL BLACKERBY

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	174H00000X	Health Educator

General Provider Information

NPI Number	:	1932791142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREL BLACKERBY

Provider Business Mailing Address
First Line	:	701 WOODCOCK LN
Second Line	:
City	:	NEW IBERIA
State	:	LA
Zip	:	70560-1466
Country	:	US
Telephone Number	:	850-585-1507
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 MIRACLE STRIP PKWY SW UNIT 5C
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5259
Country	:	US
Telephone Number	:	850-585-1507
Fax Number	:	850-400-6645

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

Provider Enumeration Date	:	02/09/2021
Last Update Date	:	02/10/2021

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Directions to “ LAUREL BLACKERBY ” Practice Location

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