Provider Demographics
NPI:1578111514
Name:BLACKBURN, MICHELLE LEE (MSN, APRN, NP-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:MSN, APRN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:255 CHURCH ST STE 101
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3476
Practice Address - Country:US
Practice Address - Phone:606-260-8613
Practice Address - Fax:859-977-2683
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2280380OtherWELLCARE OF KY PROVIDER ID NUMBER
WV1578111514Medicaid
KY7100685560Medicaid
000001412285OtherANTHEM PIN
3269903OtherHUMANA PROVIDER ID NUMBER
7480347OtherUNITED HEALTHCARE PROVIDER ID
11927004OtherPRIME HEALTH SERVICES PROVIDER ID NUMBER
VA30016213740001Medicaid
3647663OtherCIGNA PROVIDER ID NUMBER
CS2027500166OtherCARESOURCE PROVIDER ID NUMBER
2888861OtherSIHO PROVIDER ID NUMBER
KYPDZ000000623076OtherAETNA BETTER HEALTH OF KY PROVIDER ID NUMBER