Provider Demographics
NPI:1740849769
Name:BLACKWELL, KATRINA LINETTE
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:LINETTE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6134 GOLD WORTHY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6999
Mailing Address - Country:US
Mailing Address - Phone:704-207-1333
Mailing Address - Fax:
Practice Address - Street 1:6134 GOLD WORTHY CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-6999
Practice Address - Country:US
Practice Address - Phone:704-207-1333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC234128163WC1600X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1982921227Medicaid