Provider Demographics
NPI:1801138995
Name:BLACKBURN, SUZANNE RAVITA (CRNFA)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:RAVITA
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7897 SAINT ANDREWS CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-8170
Mailing Address - Country:US
Mailing Address - Phone:407-445-0215
Mailing Address - Fax:407-445-0287
Practice Address - Street 1:7897 SAINT ANDREWS CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-8170
Practice Address - Country:US
Practice Address - Phone:407-445-0215
Practice Address - Fax:407-445-0287
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3314902163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL310681100Medicaid
FLY7505OtherBCBS OF FLORIDA