Provider Demographics
NPI:1093076531
Name:BLACKBURN BOULAY, STEPHANIE ANNE (APRN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANNE
Last Name:BLACKBURN BOULAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANNE
Other - Last Name:BLACKBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2400 HARRODSBURG RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2162
Mailing Address - Country:US
Mailing Address - Phone:859-278-0319
Mailing Address - Fax:859-277-9699
Practice Address - Street 1:740 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2162
Practice Address - Country:US
Practice Address - Phone:859-323-5603
Practice Address - Fax:859-323-3704
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007414363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100203810Medicaid