Provider Demographics
NPI:1639771330
Name:BLALOCK, KATHERINE LINDSEY (ACNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LINDSEY
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:L
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4215
Mailing Address - Country:US
Mailing Address - Phone:817-335-5288
Mailing Address - Fax:817-338-0927
Practice Address - Street 1:6100 HARRIS PKWY STE 285
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4127
Practice Address - Country:US
Practice Address - Phone:817-263-5864
Practice Address - Fax:817-394-3994
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1003334363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1003334OtherNURSE PRACTITIONER LICENSE
TX831405OtherRN LICENSE