Provider Demographics
NPI:1548469588
Name:BLACKMORE, CONNIE M (RN)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:M
Last Name:BLACKMORE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-0523
Mailing Address - Country:US
Mailing Address - Phone:831-475-5853
Mailing Address - Fax:
Practice Address - Street 1:3155 CORTE CABRILLO DRIVE
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003
Practice Address - Country:US
Practice Address - Phone:831-465-1421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513345163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice