Provider Demographics
NPI:1255706602
Name:BLACKBURN, DEVON M (NP)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:M
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:DEVON
Other - Middle Name:M
Other - Last Name:LOHR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 N CAPITOL AVE
Practice Address - Street 2:NP E-140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1218
Practice Address - Country:US
Practice Address - Phone:317-962-2894
Practice Address - Fax:317-963-5285
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005960A363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201336430Medicaid
IN000000979003OtherANTHEM PTAN