Provider Demographics
NPI:1205088762
Name:BLACKBURN, PENNY KAY (LPN)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:KAY
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:KAY
Other - Last Name:BOLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 229
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:IN
Mailing Address - Zip Code:47952-0229
Mailing Address - Country:US
Mailing Address - Phone:765-585-6000
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:317-842-7674
Practice Address - Fax:800-334-9081
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-15
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27058294A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse