Provider Demographics
NPI:1083124101
Name:BLACKWELL, CAROL ANN (RN)
Entity type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 RIDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-4256
Mailing Address - Country:US
Mailing Address - Phone:607-757-2152
Mailing Address - Fax:
Practice Address - Street 1:263 RIDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-4256
Practice Address - Country:US
Practice Address - Phone:607-757-2154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290020163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool