Provider Demographics
NPI:1609857572
Name:BLACKWOOD, NICOLE P (CRNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:P
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:MAIL ROUTE 10735
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-7800
Mailing Address - Fax:612-262-7022
Practice Address - Street 1:2925 CHICAGO AVE
Practice Address - Street 2:MAIL ROUTE 10735
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1321
Practice Address - Country:US
Practice Address - Phone:612-262-7800
Practice Address - Fax:612-262-7022
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7298364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA710526GD6Medicare ID - Type Unspecified