Provider Demographics
NPI:1568718336
Name:SULLIVAN-BLACKERT, NANCI JACQULYN (RN, MSN, CDE, NP-C)
Entity Type:Individual
Prefix:
First Name:NANCI
Middle Name:JACQULYN
Last Name:SULLIVAN-BLACKERT
Suffix:
Gender:F
Credentials:RN, MSN, CDE, NP-C
Other - Prefix:
Other - First Name:NANCI
Other - Middle Name:SULLIVAN
Other - Last Name:BLACKERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3604 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7511
Mailing Address - Country:US
Mailing Address - Phone:919-876-7807
Mailing Address - Fax:919-459-8402
Practice Address - Street 1:3604 BUSH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7511
Practice Address - Country:US
Practice Address - Phone:919-876-7807
Practice Address - Fax:919-459-8402
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF0512372363LF0000X
NC5005832363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCFH4001480OtherFIRST CAROLINA CARE, INC
NCFH4001480OtherFIRST MEDICARE DIRECT
NC1568718336Medicaid
1568718336OtherHNFS/TRICARE
NCFH4001480OtherFIRST CAROLINA CARE, INC