Basic Information
| Provider Information | |||||||||
| NPI: | 1568718336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN-BLACKERT | ||||||||
| FirstName: | NANCI | ||||||||
| MiddleName: | JACQULYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, MSN, CDE, NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BLACKERT | ||||||||
| OtherFirstName: | NANCI | ||||||||
| OtherMiddleName: | SULLIVAN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3604 BUSH ST | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198767807 | ||||||||
| FaxNumber: | 9194598402 | ||||||||
| Practice Location | |||||||||
| Address1: | 3604 BUSH ST | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198767807 | ||||||||
| FaxNumber: | 9194598402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2012 | ||||||||
| LastUpdateDate: | 08/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F0512372 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 5005832 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | FH4001480 | 01 | NC | FIRST CAROLINA CARE, INC | OTHER | FH4001480 | 01 | NC | FIRST MEDICARE DIRECT | OTHER | 1568718336 | 05 | NC | MEDICAID | 1568718336 | 01 | HNFS/TRICARE | OTHER |