Provider Demographics
NPI:1174294227
Name:BLACKBURN, DONALD EDWARD (APRN)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:EDWARD
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7818 PEAR VIEW LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4761
Mailing Address - Country:US
Mailing Address - Phone:502-552-5512
Mailing Address - Fax:
Practice Address - Street 1:2000 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9454
Practice Address - Country:US
Practice Address - Phone:270-506-2730
Practice Address - Fax:270-900-0704
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016712363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty