Provider Demographics
NPI:1861005589
Name:BLACKBURN, GLADYS (NP)
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:GLADYS
Other - Middle Name:
Other - Last Name:ALALADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:285 W 12TH ST STE 206
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1654
Mailing Address - Country:US
Mailing Address - Phone:765-472-5335
Mailing Address - Fax:
Practice Address - Street 1:285 W 12TH ST STE 206
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1654
Practice Address - Country:US
Practice Address - Phone:765-472-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28222639A163W00000X
IN71010379A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse