Provider Demographics
NPI:1417020405
Name:BLACKBURNE, KIZUWANDA (RPAC)
Entity Type:Individual
Prefix:
First Name:KIZUWANDA
Middle Name:
Last Name:BLACKBURNE
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 EAGLES WALK
Mailing Address - Street 2:SUITE A
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7340
Mailing Address - Country:US
Mailing Address - Phone:770-389-3855
Mailing Address - Fax:770-474-8078
Practice Address - Street 1:145 EAGLES WALK
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7340
Practice Address - Country:US
Practice Address - Phone:770-389-3855
Practice Address - Fax:770-474-8078
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA061407OtherBCBS OF GA GROUP #