Provider Demographics
NPI:1437583390
Name:BLAKEMORE, SUSAN LYNNE (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNNE
Last Name:BLAKEMORE
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 1:3743 LANDMARK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6656
Mailing Address - Country:US
Mailing Address - Phone:765-448-4511
Mailing Address - Fax:
Practice Address - Street 1:3743 LANDMARK DR
Practice Address - Street 2:STE 200
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6656
Practice Address - Country:US
Practice Address - Phone:765-448-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF1214194363LF0000X
INA0213010363LA2200X
IN71004535A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health