Provider Demographics
NPI:1669904108
Name:BLACKMON HUMPHREY, EBONY (DNP ARNP PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:EBONY
Middle Name:
Last Name:BLACKMON HUMPHREY
Suffix:
Gender:F
Credentials:DNP ARNP PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 NW GILMAN BLVD UNIT 2862
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-0258
Mailing Address - Country:US
Mailing Address - Phone:206-701-9363
Mailing Address - Fax:
Practice Address - Street 1:23205 SE BLACK NUGGET RD
Practice Address - Street 2:APT J2
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029-7326
Practice Address - Country:US
Practice Address - Phone:206-701-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60625891163W00000X, 163WC0400X, 163WP0808X
WAAP60929540363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health