Provider Demographics
NPI:1326265430
Name:BLACKWELL, TARA DESHEE (APRN)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:DESHEE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:DESHEE
Other - Last Name:HILDRETH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2605 KENTUCKY AVE
Practice Address - Street 2:STE. 102
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-415-8965
Practice Address - Fax:855-855-4585
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3005131363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100096070Medicaid
KY00931010Medicare PIN
KYK157260Medicare PIN