Provider Demographics
NPI:1154027829
Name:BLACKBURN, NICHOLE MARIE (FNP-C)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MARIE
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 HEFNER POINTE DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5039
Mailing Address - Country:US
Mailing Address - Phone:405-749-9655
Mailing Address - Fax:405-749-1001
Practice Address - Street 1:522 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4241
Practice Address - Country:US
Practice Address - Phone:580-243-2200
Practice Address - Fax:580-303-4712
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK211675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily