Provider Demographics
NPI:1891014478
Name:BLACKWOOD, LUXIA (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:LUXIA
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 EASTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-2426
Mailing Address - Country:US
Mailing Address - Phone:347-623-4702
Mailing Address - Fax:
Practice Address - Street 1:36 EASTWOOD LN
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-2426
Practice Address - Country:US
Practice Address - Phone:347-623-4702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-22
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308780363LG0600X
NY585608-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse