Provider Demographics
NPI:1821606500
Name:BLAIN, MAKAYLA (NP)
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:
Last Name:BLAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MAKAYLA
Other - Middle Name:
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1721 MAGNAVOX WAY
Mailing Address - Street 2:STE B
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1537
Mailing Address - Country:US
Mailing Address - Phone:260-748-3650
Mailing Address - Fax:260-748-3651
Practice Address - Street 1:1721 MAGNAVOX WAY
Practice Address - Street 2:STE B
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1537
Practice Address - Country:US
Practice Address - Phone:260-748-3650
Practice Address - Fax:260-748-3651
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010155A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300040816Medicaid