Provider Demographics
NPI:1619242674
Name:YOUNGBLOOD, CAROLINE BLAKE ELLENBURG (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE BLAKE
Middle Name:ELLENBURG
Last Name:YOUNGBLOOD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:CAROLINE
Other - Middle Name:BLAKE
Other - Last Name:ELLENBURG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:504 BROOKWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-6802
Mailing Address - Country:US
Mailing Address - Phone:205-871-9661
Mailing Address - Fax:205-870-1621
Practice Address - Street 1:504 BROOKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6802
Practice Address - Country:US
Practice Address - Phone:205-871-9661
Practice Address - Fax:205-870-1621
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15875363LF0000X
AL1-120527363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily