Provider Demographics
NPI:1366622086
Name:BLACKMAN, MICHELLE JEANNE (ARNP)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:JEANNE
Last Name:BLACKMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 WOOLWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68105-1850
Mailing Address - Country:US
Mailing Address - Phone:402-995-4309
Mailing Address - Fax:402-995-5968
Practice Address - Street 1:4101 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1850
Practice Address - Country:US
Practice Address - Phone:402-995-4309
Practice Address - Fax:402-995-5968
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA108976174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA108976OtherSTATE LICENSE