Provider Demographics
NPI:1033372081
Name:BLACKETT, ANGIE RENA (RN, CPM, LDEM)
Entity Type:Individual
Prefix:MRS
First Name:ANGIE
Middle Name:RENA
Last Name:BLACKETT
Suffix:
Gender:F
Credentials:RN, CPM, LDEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14443 S CHROME RD
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1204
Mailing Address - Country:US
Mailing Address - Phone:801-200-1873
Mailing Address - Fax:
Practice Address - Street 1:14443 S CHROME RD
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-1204
Practice Address - Country:US
Practice Address - Phone:801-200-1873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT286486-3400OtherSTATE LICENSE
08100017OtherNORTH AMERICAN REGISTRY OF MIDWIVES
UT286486-3102OtherUTAH STATE BOARD OF NURSING