Provider Demographics
NPI:1245899616
Name:BLACKBURN, ANGELA YVETTE (AGPNP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:YVETTE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:AGPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:615 RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-4629
Practice Address - Country:US
Practice Address - Phone:336-503-5623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011847363L00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist