Provider Demographics
NPI:1891945408
Name:BLACKETER, AUDREY NICOLE (CF)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:NICOLE
Last Name:BLACKETER
Suffix:
Gender:F
Credentials:CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 CROSBY DR
Mailing Address - Street 2:#917
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1811
Mailing Address - Country:US
Mailing Address - Phone:270-535-8791
Mailing Address - Fax:
Practice Address - Street 1:3900 CROSBY DR
Practice Address - Street 2:#917
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-1811
Practice Address - Country:US
Practice Address - Phone:270-535-8791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-08-007235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist