1225114143 NPI number — DR. ANGELA CHISUM BLACKBURN PH.D., A.R.N.P.

Table of content: DR. ANGELA CHISUM BLACKBURN PH.D., A.R.N.P. (NPI 1225114143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225114143 NPI number — DR. ANGELA CHISUM BLACKBURN PH.D., A.R.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKBURN
Provider First Name:
ANGELA
Provider Middle Name:
CHISUM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., A.R.N.P.
Provider Gender Code:
F

Provider's Other Name Information

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 Information

NPI Number:
1225114143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 SAWGRASS CORPORATE PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-243-3839
Provider Business Mailing Address Fax Number:
954-838-9961

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5149 N 9TH AVE
Provider Second Line Business Practice Location Address:
SUITE G-27
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32504-8756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-416-4417
Provider Business Practice Location Address Fax Number:
850-416-7253
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LN0005X , with the licence number:  2080252 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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