Provider Demographics
NPI:1902336431
Name:BLACKBURN, CAROLYN ANN (FNP-C)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2303 VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-4954
Mailing Address - Country:US
Mailing Address - Phone:816-307-4893
Mailing Address - Fax:816-232-2991
Practice Address - Street 1:245 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-3031
Practice Address - Country:US
Practice Address - Phone:660-752-9006
Practice Address - Fax:660-258-9006
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008017992163W00000X
MO2017032960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420047801Medicaid