Provider Demographics
NPI:1922835552
Name:BLACKWOOD, NATALIE
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:BLACKWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 N SOUTHPORT AVE APT 3S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3581
Mailing Address - Country:US
Mailing Address - Phone:973-897-5617
Mailing Address - Fax:
Practice Address - Street 1:3718 N SOUTHPORT AVE APT 3S
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3581
Practice Address - Country:US
Practice Address - Phone:973-897-5617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-029899363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics