Provider Demographics
NPI:1750099305
Name:BLACKWELL, TAYLOR RENEE (DNP, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:RENEE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:DNP, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 HIGHWAY 39 N APT 14B
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1076
Mailing Address - Country:US
Mailing Address - Phone:601-604-7688
Mailing Address - Fax:
Practice Address - Street 1:1314 19TH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4116
Practice Address - Country:US
Practice Address - Phone:601-483-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS907045363LA2100X
MS910231163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse