Provider Demographics
NPI:1467839324
Name:BLACKWELL, COURTNEY B (RN, MSN, AGNP AANP-C)
Entity Type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:B
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:RN, MSN, AGNP AANP-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:PO BOX 847692
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7692
Mailing Address - Country:US
Mailing Address - Phone:806-331-7905
Mailing Address - Fax:806-731-1516
Practice Address - Street 1:1000 CRAIG DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-4015
Practice Address - Country:US
Practice Address - Phone:806-331-7905
Practice Address - Fax:806-731-1516
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126365363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3456659-01Medicaid
TX410979ZHVZMedicare PIN