Provider Demographics
NPI:1851042857
Name:BLACKBURN, CRYSTAL (CRNA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 E 200 S
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:UT
Mailing Address - Zip Code:84333-1614
Mailing Address - Country:US
Mailing Address - Phone:435-232-5911
Mailing Address - Fax:
Practice Address - Street 1:555 S TELSHOR BLVD STE 100B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-3644
Practice Address - Country:US
Practice Address - Phone:435-232-5911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8054927-3102163W00000X
TX1073748367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse