Provider Demographics
NPI:1487656708
Name:BLACKBURN, VICKIE MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:MARIE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 604350
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4350
Mailing Address - Country:US
Mailing Address - Phone:704-364-8100
Mailing Address - Fax:704-365-2073
Practice Address - Street 1:1721 EBENEZER RD STE 175
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1188
Practice Address - Country:US
Practice Address - Phone:803-324-5256
Practice Address - Fax:803-328-0440
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5014444363L00000X
SC2650363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ53975Medicare UPIN