Provider Demographics
NPI:1902826621
Name:BLACKMON, MARCY O (CRNA)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:O
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:D
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1968 PEACHTREE ROAD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1281
Practice Address - Country:US
Practice Address - Phone:404-351-1745
Practice Address - Fax:404-351-7121
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA149840367500000X
GARN149840367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA358894148Medicaid
GA358894148Medicaid
43BBBHSMedicare ID - Type Unspecified