Provider Demographics
NPI:1821398397
Name:BLACKWELL, WYVON (MSN, APRN,FNP-C)
Entity Type:Individual
Prefix:MS
First Name:WYVON
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MSN, APRN,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-3556
Mailing Address - Country:US
Mailing Address - Phone:708-596-5177
Mailing Address - Fax:708-596-5518
Practice Address - Street 1:31 W 155TH ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426
Practice Address - Country:US
Practice Address - Phone:708-596-5177
Practice Address - Fax:708-596-5518
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28180607A171M00000X
ILF0214515363LF0000X
IL309007962363LF0000X
IL209011447363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209011447Medicaid