Basic Information
Provider Information | |||||||||
NPI: | 1225114143 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACKBURN | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | CHISUM | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D., A.R.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1300 SAWGRASS CORPORATE PKWY | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SUNRISE | ||||||||
State: | FL | ||||||||
PostalCode: | 333232826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8002433839 | ||||||||
FaxNumber: | 9548389961 | ||||||||
Practice Location | |||||||||
Address1: | 5149 N 9TH AVE | ||||||||
Address2: | SUITE G-27 | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325048756 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504164417 | ||||||||
FaxNumber: | 8504167253 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2006 | ||||||||
LastUpdateDate: | 02/16/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | 2080252 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
No ID Information.