Provider Demographics
NPI:1104470079
Name:BLACKPORT, KATHRYN MICHELE (MSN, CNM)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MICHELE
Last Name:BLACKPORT
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:READING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3915 ELMHURST AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1862
Mailing Address - Country:US
Mailing Address - Phone:586-604-8350
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470407657176B00000X
MI4704307657367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife