Provider Demographics
NPI:1700857216
Name:BLACKBURN, SALLY (NP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:
Other - Last Name:PENNINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:SALTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24370-0729
Mailing Address - Country:US
Mailing Address - Phone:276-496-4492
Mailing Address - Fax:276-496-4839
Practice Address - Street 1:2195 EUCLID AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3655
Practice Address - Country:US
Practice Address - Phone:276-669-5179
Practice Address - Fax:276-466-8870
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024164957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ006676Medicaid
VAP42395Medicare UPIN
TN103I500911Medicare PIN
TNQ006676Medicaid
VA500000973Medicare PIN