Provider Demographics
NPI:1689245466
Name:BLACKBURN, HOLLY ANGELA
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:ANGELA
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HICKORY CV
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35634-2306
Mailing Address - Country:US
Mailing Address - Phone:256-710-9642
Mailing Address - Fax:
Practice Address - Street 1:1300 S MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-6334
Practice Address - Country:US
Practice Address - Phone:256-710-9642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-02
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-089407363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care