Provider Demographics
NPI:1598811663
Name:BLACKWELL, ANNIE DELORES (CRNA)
Entity Type:Individual
Prefix:MS
First Name:ANNIE
Middle Name:DELORES
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:DELORES
Other - Last Name:MANNING
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:117 E KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5201
Mailing Address - Country:US
Mailing Address - Phone:336-623-9711
Mailing Address - Fax:
Practice Address - Street 1:117 E KINGS HWY
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5201
Practice Address - Country:US
Practice Address - Phone:336-623-9711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC072294367500000X
VA0024165671367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051039Medicaid
NC2600161GMedicare ID - Type Unspecified
NC8051039Medicaid