Provider Demographics
NPI:1679839138
Name:BLACKMON, WILLIAM DAVID (RN, FNP-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 EAST ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-3408
Mailing Address - Country:US
Mailing Address - Phone:530-365-2545
Mailing Address - Fax:
Practice Address - Street 1:2830 EAST ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3408
Practice Address - Country:US
Practice Address - Phone:530-365-2545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2013-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21914363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily