Provider Demographics
NPI:1437195823
Name:BLACKWELL, CONNIE SUE (RN CNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:RN CNP
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:SUE
Other - Last Name:AMUNDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10081 DOGWOOD ST NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-5281
Mailing Address - Country:US
Mailing Address - Phone:763-783-3722
Mailing Address - Fax:763-783-7944
Practice Address - Street 1:10081 DOGWOOD ST NW
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-5281
Practice Address - Country:US
Practice Address - Phone:763-783-3722
Practice Address - Fax:763-783-7944
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA0813103363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2911984200Medicaid
MN31257BLOtherBLUE CROSS BLUE SHIELD
MN1203352OtherMEDICA
MN1203352OtherMEDICA
500003073Medicare ID - Type Unspecified