Provider Demographics
NPI:1891709572
Name:BLAKENEY, SUSAN E (FNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:BLAKENEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5700
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5700
Practice Address - Fax:601-268-5777
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR724653363L00000X
MS724653363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122059Medicaid
MS00122059Medicaid
MS640507572YLOtherAMERICAN ADMIN GROUP
MS1891709572OtherHEALTHSPRING
MS1891709572OtherHEALTHSPRING
P82684Medicare UPIN