Provider Demographics
NPI:1497579247
Name:BLACKWELL, CASEY MARIE (APRN)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:MARIE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:487 S BLUFORD AVE
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-2748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 W STATE ROAD 434
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5119
Practice Address - Country:US
Practice Address - Phone:321-842-8505
Practice Address - Fax:321-843-5550
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL11035131363LA2100X
FLAPRN11035131363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care