Provider Demographics
NPI:1700495637
Name:BLACKHURST, STEPHEN JEFFERY II (RN)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JEFFERY
Last Name:BLACKHURST
Suffix:II
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 CHAMPAGNE CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6787
Mailing Address - Country:US
Mailing Address - Phone:407-545-0877
Mailing Address - Fax:
Practice Address - Street 1:444 CHAMPAGNE CIR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-6787
Practice Address - Country:US
Practice Address - Phone:407-545-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9273773163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse