Provider Demographics
NPI:1063228468
Name:BLACKBURN, SIARA SOUTHERLAND
Entity type:Individual
Prefix:
First Name:SIARA
Middle Name:SOUTHERLAND
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIARA
Other - Middle Name:NICOLE
Other - Last Name:SOUTHERLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:BUIES CREEK
Mailing Address - State:NC
Mailing Address - Zip Code:27506-0563
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 563
Practice Address - Street 2:
Practice Address - City:BUIES CREEK
Practice Address - State:NC
Practice Address - Zip Code:27506-0563
Practice Address - Country:US
Practice Address - Phone:910-742-7823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-10
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program