Provider Demographics
NPI:1679558167
Name:BLACKBURN, MONICA (CRNA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DRIVE #258
Mailing Address - Street 2:INDEPENDENT ANESTHESIOLOGISTS PSC
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017
Mailing Address - Country:US
Mailing Address - Phone:859-341-7246
Mailing Address - Fax:859-341-7867
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:INDEPENDENT ANESTHESIOLOGISTS PSC
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-341-7246
Practice Address - Fax:859-341-7867
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1047367367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000288565OtherBLUE SHIELD
IN200416410Medicaid
KY74476144Medicaid
OH2380963Medicaid
000000288565OtherBLUE SHIELD
IN200416410Medicaid