Basic Information
| Provider Information | |||||||||
| NPI: | 1922494657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | CONSTANCE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN MSN NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARROLL | ||||||||
| OtherFirstName: | CHRISTIAN | ||||||||
| OtherMiddleName: | CONSTANCE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1005 MAR WALT DR | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508638100 | ||||||||
| FaxNumber: | 8508638548 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 MAR WALT DRIVE | ||||||||
| Address2: | INTERNAL MEDICINE DEPARTMENT | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508638202 | ||||||||
| FaxNumber: | 8508626148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2015 | ||||||||
| LastUpdateDate: | 09/25/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | APRN9171045 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.