Provider Demographics
NPI:1295586196
Name:BLACKBURN, TRACI (FNP)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 I45 S.
Mailing Address - Street 2:BUILDING A
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340
Mailing Address - Country:US
Mailing Address - Phone:281-975-1000
Mailing Address - Fax:
Practice Address - Street 1:643 I45 S.
Practice Address - Street 2:BUILDING A
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340
Practice Address - Country:US
Practice Address - Phone:281-975-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2025-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX888082163W00000X
TX1215344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse