Provider Demographics
NPI:1659509982
Name:BLACKBURN, KAITLIN ANN (RN)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ANN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25827-0365
Mailing Address - Country:US
Mailing Address - Phone:304-860-1253
Mailing Address - Fax:
Practice Address - Street 1:118 SHEPHERD LANE
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827
Practice Address - Country:US
Practice Address - Phone:304-860-1253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVTEMP00924163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse