Provider Demographics
NPI:1942381660
Name:BLACKBURN, LISA M (CNS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD
Mailing Address - Street 2:STE 570
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1579
Mailing Address - Country:US
Mailing Address - Phone:614-947-3700
Mailing Address - Fax:
Practice Address - Street 1:300 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1280
Practice Address - Country:US
Practice Address - Phone:614-425-0257
Practice Address - Fax:614-293-6420
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS05202 RN 204106364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2511400Medicaid
P97220Medicare UPIN
OHNS04711Medicare PIN