Provider Demographics
NPI:1720623499
Name:DEBOARD, BLAKELY AUSTIN
Entity Type:Individual
Prefix:MR
First Name:BLAKELY
Middle Name:AUSTIN
Last Name:DEBOARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6918 NEOPOLITAN CT
Mailing Address - Street 2:
Mailing Address - City:APOLLO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33572-1604
Mailing Address - Country:US
Mailing Address - Phone:813-304-3383
Mailing Address - Fax:
Practice Address - Street 1:6000 49TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2114
Practice Address - Country:US
Practice Address - Phone:727-521-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-16
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9444134163W00000X
FLAPRN11005487367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse