Basic Information
Provider Information | |||||||||
NPI: | 1326265430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACKWELL | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | DESHEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HILDRETH | ||||||||
OtherFirstName: | TARA | ||||||||
OtherMiddleName: | DESHEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | APRN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 776351 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606776351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025889490 | ||||||||
FaxNumber: | 5022725116 | ||||||||
Practice Location | |||||||||
Address1: | 2605 KENTUCKY AVE | ||||||||
Address2: | STE. 102 | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420033800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2704158965 | ||||||||
FaxNumber: | 8558554585 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2007 | ||||||||
LastUpdateDate: | 03/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3005131 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LW0102X | 3005131 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
ID | Type | State | Issuer | Description | 7100096070 | 05 | KY |   | MEDICAID |