Provider Demographics
NPI:1710002670
Name:BLACKBURN, KIM ANN
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:ANN
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 1:1220 LYNNE AVE
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-3013
Mailing Address - Country:US
Mailing Address - Phone:419-564-2143
Mailing Address - Fax:
Practice Address - Street 1:1220 LYNNE AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-3013
Practice Address - Country:US
Practice Address - Phone:419-564-2143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2426253390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program