1578111514 NPI number — MICHELLE LEE BLACKBURN MSN, APRN, NP-C

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578111514 NPI number — MICHELLE LEE BLACKBURN MSN, APRN, NP-C

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

BLACKBURN

Provider First Name:

MICHELLE

Provider Middle Name:

LEE

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MSN, APRN, NP-C

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1578111514

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

02/13/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 21890

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

BELFAST

Provider Business Mailing Address State Name:

ME

Provider Business Mailing Address Postal Code:

04915-4115

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

502-907-0356

Provider Business Mailing Address Fax Number:

502-919-9780

Provider First Line Business Practice Location Address:

255 CHURCH ST STE 101

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

PIKEVILLE

Provider Business Practice Location Address State Name:

KY

Provider Business Practice Location Address Postal Code:

41501-3476

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

606-260-8613

Provider Business Practice Location Address Fax Number:

859-977-2683

Provider Enumeration Date:

09/03/2019

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363LF0000X , with the licence number:  3013692 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 2280380 . This is a "WELLCARE OF KY PROVIDER ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 1578111514 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
• Identifier: 7100685560 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
• Identifier: 000001412285 . This is a "ANTHEM PIN" identifier . This identifiers is of the category "OTHER".
• Identifier: 3269903 . This is a "HUMANA PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 7480347 . This is a "UNITED HEALTHCARE PROVIDER ID" identifier . This identifiers is of the category "OTHER".
• Identifier: 11927004 . This is a "PRIME HEALTH SERVICES PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 30016213740001 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
• Identifier: 3647663 . This is a "CIGNA PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: CS2027500166 . This is a "CARESOURCE PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: 2888861 . This is a "SIHO PROVIDER ID NUMBER" identifier . This identifiers is of the category "OTHER".
• Identifier: PDZ000000623076 . This is a "AETNA BETTER HEALTH OF KY PROVIDER ID NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".