Provider Demographics
NPI:1609589225
Name:BLACKWELL, MARYANN (APRN)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 GOLDENROD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-2728
Mailing Address - Country:US
Mailing Address - Phone:682-330-8191
Mailing Address - Fax:
Practice Address - Street 1:1325 PENNSYLVANIA AVE STE 890
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2145
Practice Address - Country:US
Practice Address - Phone:817-250-7230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1092615363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care