Basic Information
| Provider Information | |||||||||
| NPI: | 1952551525 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1510 | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087850940 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 BLACKHAWK AVENUE | ||||||||
| Address2: | |||||||||
| City: | PRAIRIE DU CHIEN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083260808 | ||||||||
| FaxNumber: | 6083260810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2008 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 52150 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.