Provider Demographics
NPI:1255562575
Name:BLACKWELL, CASSIE LYN (FNP)
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:LYN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:FNP
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 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 HARRY HINES BLVD
Practice Address - Street 2:HOMES GROUP
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7721
Practice Address - Country:US
Practice Address - Phone:214-590-0153
Practice Address - Fax:214-590-0172
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX687599363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX203848101Medicaid
TX805N81OtherBLUE CROSS BLUE SHIELD
TX8L18072Medicare PIN