Provider Demographics
NPI:1821340654
Name:BLACKWELL, TERRI LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:LYNN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 HOSPITAL DR STE 150
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3243
Mailing Address - Country:US
Mailing Address - Phone:843-971-9350
Mailing Address - Fax:843-971-9351
Practice Address - Street 1:851 LEONARD FULGHUM DR STE 101
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3793
Practice Address - Country:US
Practice Address - Phone:843-971-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL 1833363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant