Provider Demographics
NPI:1902570088
Name:BLACKMON, KATELYN (WHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:
Last Name:BLACKMON
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8038 N 600 W STE 100
Mailing Address - Street 2:
Mailing Address - City:MCCORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-8605
Mailing Address - Country:US
Mailing Address - Phone:317-932-3426
Mailing Address - Fax:855-631-0165
Practice Address - Street 1:1210B MEDICAL ARTS BLVD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3435
Practice Address - Country:US
Practice Address - Phone:765-563-2843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ259154363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty