Basic Information
| Provider Information | |||||||||
| NPI: | 1144467002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | NAOMI | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | R.N., C.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23030 STATE ROUTE 73 | ||||||||
| Address2: | |||||||||
| City: | WEST PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456638861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408581063 | ||||||||
| FaxNumber: | 7408589140 | ||||||||
| Practice Location | |||||||||
| Address1: | 23030 STATE ROUTE 73 | ||||||||
| Address2: | |||||||||
| City: | WEST PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456638861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408581063 | ||||||||
| FaxNumber: | 7408589140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2009 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN241001 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | COA.10506-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100086520 | 05 | KY | MEDICAID | 1003908930 | 01 | FACILITY NPI # | OTHER | 2954272 | 05 | OH | MEDICAID | RN241001 | 01 | OH | LICENSE NUMBER | OTHER |