Provider Demographics
NPI:1730748757
Name:BLICKHAHN, AMY LEIGH (RN, BSN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LEIGH
Last Name:BLICKHAHN
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28755 EL TORO RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-1912
Mailing Address - Country:US
Mailing Address - Phone:951-249-4693
Mailing Address - Fax:
Practice Address - Street 1:28755 EL TORO RD
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92532-1912
Practice Address - Country:US
Practice Address - Phone:951-249-4693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA476931163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool