Provider Demographics
NPI:1639792955
Name:BLACKMON, HAROLD TODD (FNP)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:TODD
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 VILLAGE PROFESSIONAL DR N
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-4784
Mailing Address - Country:US
Mailing Address - Phone:334-528-5400
Mailing Address - Fax:334-528-5421
Practice Address - Street 1:2601 VILLAGE PROFESSIONAL DR N
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-4784
Practice Address - Country:US
Practice Address - Phone:334-528-5400
Practice Address - Fax:334-528-5421
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-081439363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty