Provider Demographics
NPI:1811534613
Name:BLACKBURN, SAMANTHA D'ANN (AGACNP - BC; FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:D'ANN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:AGACNP - BC; FNP-C
Other - Prefix:MS
Other - First Name:SAMANTHA
Other - Middle Name:D'ANN
Other - Last Name:FUNDINGSLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:808 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2437
Mailing Address - Country:US
Mailing Address - Phone:208-452-2672
Mailing Address - Fax:
Practice Address - Street 1:808 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2437
Practice Address - Country:US
Practice Address - Phone:208-452-2672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-29
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID47259163W00000X
ID65041363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care